Fluent Essays

I have bioethics questions that needed to be answered. I will supply with all the material. there are 16 questions that needed to be answered. each question need 1-2 paragraph. Each question is goo 1 paragraph. we are talking about probably 8-9 pages SPECIESISM AND MORAL STATUS PETER SINGER Abstract: Many people believe that all human life is of equal value. Most of them also believe that all human beings have a moral status superior to that of nonhuman animals. But how are these beliefs to be defended? The mere difference of species cannot in itself determine moral status. The most obvious candidate for regarding human beings as having a higher moral status than animals is the superior cognitive capacity of humans. People with profound mental retardation pose a problem for this set of beliefs, because their cognitive capacities are not superior to those of many animals. I argue that we should drop the belief in the equal value of human life, replacing it with a graduated view that applies to animals as well as to humans. Keywords: speciesism, animals, disability, ethics, moral status. Introduction This essay derives from a talk presented at the conference ‘‘Cognitive Disability: A Challenge to Moral Philosophy.’’ 1 As that title suggests, cognitive disability does present a challenge to moral philosophy. I focus here on the challenge it presents to views about moral status that are widespread both among moral philosophers and in the wider community. However, the reverse is also true: moral philosophy can and ought to challenge how we think about people with cognitive disabilities and about the value of human life. I want to enlarge the sphere of discussion, so that we are looking not just at people with cognitive disabilities but also at the way in which our thoughts about moral status relate to beings who do not have the cognitive abilities that normal humans have. Although there is among some who write on cognitive disability a strong aversion to 1 The conference was held at Stony Brook University in New York City in September 2008. I dedicate these thoughts to Harriet McBryde Johnson because my presentation at the conference was the first time since she died that I spoke on issues of intellectual disability. In recent years, while she lived, whenever I spoke or wrote about intellectual disability, I could expect an e-mail from her telling me where I was wrong. Knowing that my work would receive her sharp scrutiny was a spur to defending my views as well as I could. Sadly I’m not going to hear from her this time. r 2009 The Author Journal compilation r 2009 Metaphilosophy LLC and Blackwell Publishing Ltd Published by Blackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK, and 350 Main Street, Malden, MA 02148, USA METAPHILOSOPHY Vol. 40, Nos. 3–4, July 2009 0026-1068 r 2009 The Author Journal compilation r 2009 Metaphilosophy LLC and Blackwell Publishing Ltd comparing humans with nonhuman animals, these comparisons are unavoidable if we are to clarify the basis of moral status. Hence I begin with some examples of cognitive abilities that show significant overlap between some nonhuman animals and some human beings. I then discuss the widely accepted ethic of ‘‘the equal value and dignity of all human life,’’ and the various grounds—religious, speciesist, cognitive-ability-based, and ‘‘slippery slope’’—on which people have attempted to support this ethic. I argue that this view of universal and equal human dignity cannot be supported without a drastic revision to aspects of our morality, which most people do not want to make. As an alternative, I present a graduated view of the moral status of humans and nonhuman animals. Cognitive Abilities in Humans and Animals Let us consider a few examples of the capacities and cognitive abilities of nonhuman beings, with regard to IQ and language comprehension. I specifically want to consider research done on great apes, border collies, and grey parrots. Great apes: Francine Patterson of the Gorilla Foundation claims that the gorilla Koko scored between 70 and 95 on human IQ tests and understands about a thousand signs. Though this finding is controversial, there is a substantial amount of uncontroversial research suggesting that many of the great apes, including gorillas, chimpanzees, bonobos, and orangutans, can use human sign language and can develop a fair range of comprehension. 2 At least, it is clear that they understand a number of signs, and they use a kind of structured syntax. The question of whether or not we should call this ‘‘language’’ is not my concern here. What is relevant for this discussion is comparisons with humans with cognitive disabilities; the point being that if we raise the standard for language to exclude the signs used by Koko, Kanzi, Washoe, Chantek, or some of the other signing apes, then we would have to say that some humans at profound and severe levels of cognitive disability don’t have language either. We must keep a level playing field for comparisons between species—in this case between some humans with cognitive disabilities and great apes. Dogs: There’s been some interesting recent work on dogs’ abilities to recognize human spoken language. Border collies, when presented with a collection of hundreds of different toys with different names, are able to respond and fetch a particular named object. Tests have demonstrated that they can comprehend two hundred to three hundred human words. 3 2 See, for example, the essays in part 2 of Paola Cavalieri and Peter Singer, eds., The Great Ape Project: Equality Beyond Humanity (New York: St. Martin’s Press, 1994). 3 See the research by Juliane Kamiski and Sebastian Tempelmann, cited by Virginia Morell in ‘‘Minds of Their Own,’’ National Geographic, March 2008. r 2009 The Author Journal compilation r 2009 Metaphilosophy LLC and Blackwell Publishing Ltd PETER SINGER568 Grey parrots: Remarkable work was done by Irene Pepperberg with Alex, an African grey parrot, who died recently. Alex grasped about a hundred words; of course, parrots are actually grasping spoken human language and responding to it in the same spoken language—no sign language here. Alex—and this also goes for other grey parrots that are being studied—was shown to be not just ‘‘parroting,’’ because he could answer novel questions. Furthermore, his answers to the questions showed a grasp of concepts. For example, if Alex was shown a yellow sphere and a yellow cube and was then asked, ‘‘What’s the same?’’ he would answer, ‘‘Color.’’ When shown a red sphere and a yellow sphere and asked, ‘‘What’s the same?’’ Alex would say, ‘‘Shape.’’ So it seems clear that Alex understood what was going on with these basic concepts, and he had modest numerical ability as well, being able to count up to seven. 4 Having considered these examples of nonhuman animal cognitive ability, let’s look at some human beings with cognitive disabilities. I’m focusing here on the very bottom of the range: those with profound mental retardation, and I acknowledge that this is a very small percentage of people with intellectual disabilities. In fact, the American Association for Intellectual and Developmental Disabilities says it’s 1 percent. Other statistics are available that vary slightly on this, but the point is not so much how many human beings there are in this category but rather the fact that there are some, for they form the basis on which I will later raise arguments about claims that all human beings have a certain kind of moral status. I recognize that for those with a particular concern for people with cognitive disabilities, this may make what I’m saying less interesting because I am going to make an argument that concerns the moral status of human beings in general, as compared to nonhuman animals. There may also be some who are working with people with disabilities or who are caregivers or relatives of people with cognitive disabilities who will look at my examples of severe and profound cognitive disability and say to themselves that I am not discussing people who are like the people that they work with or care for. I acknowledge, of course, that people with cognitive disabilities are not easy to categorize. Obviously the issues are different depending on the severity of the cognitive disabilities. But let me reiterate that for the moment I have in mind those with profound mental retardation as defined below, and the definition is not mine. According to the American Association on Intellectual and Develop- mental Disabilities, people with profound mental retardation � have an IQ range below 25; � will always require much supervision, though they may acquire some self-help skills; 4 See Irene Pepperberg, The Alex Studies: Cognitive and Communicative Abilities of Grey Parrots (Cambridge, Mass.: Harvard University Press, 1999). r 2009 The Author Journal compilation r 2009 Metaphilosophy LLC and Blackwell Publishing Ltd SPECIESISM AND MORAL STATUS 569 � have an ability to understand that exceeds their ability to speak; � may have little or no speech; � may be capable of following simple directions; � have no academic skills; � may be unable to perform any useful work, though with training may be able to achieve a work-activity level of productivity; � may appear socially isolated and pay little attention to others except as it relates to their own needs. 5 Now let us think about nonhuman animals in terms of these capacities. � IQ: Some nonhuman animals, such as the gorilla Koko, have IQ ranges significantly above 25. � Supervision: Animals don’t require much supervision—many of them get on and always have got on with their lives perfectly well— often better—without human interference. � Speech: It is generally true that nonhuman animals have little or no speech, or what we would call speech, although, as we have seen, there are exceptions. � Following simple directions: Many animals, including dogs, can follow simple directions. Can they acquire skills? Dogs, horses, dolphins, pigeons, and several other animals can be trained to perform useful work. In fact, one of the reasons why it is thought that border collies are good at following human commands is that traditionally they have been bred to work with sheep and to respond to commands to separate some sheep from others. � Social isolation: We are not the only social animals; there is clearly a wide range of social mammals for whom sociability is very important. All of the great apes, primates generally, dogs, and many other nonhuman animals are social beings and develop in society, respond to the needs of other beings in their group, communicate with them, reciprocate certain kinds of behavior, and so on. Given that there are some humans who are profoundly mentally retarded and have the characteristics listed above, it is clearly not the case that all humans have cognitive ability above all nonhuman animals. On the contrary, we have many nonhuman animals who are significantly above some human beings in their level of cognitive ability: in particular, they are above those with profound mental retardation. Our question is: What ethical significance can we draw from this? 5 Quoted from Taskforce Independence, ‘‘Supported Accommodation for All Who Need It: A Reality, Not a Dream,’’ available at www.nds.org.au/nsw/Conferences/2007annual/ papers/3.1b_Discussion\%20Paper_Australia.doc. I have been unable to trace the original source. r 2009 The Author Journal compilation r 2009 Metaphilosophy LLC and Blackwell Publishing Ltd PETER SINGER570 www.nds.org.au/nsw/Conferences/2007annual/papers/3.1b_Discussion\%20Paper_Australia.doc. www.nds.org.au/nsw/Conferences/2007annual/papers/3.1b_Discussion\%20Paper_Australia.doc. www.nds.org.au/nsw/Conferences/2007annual/papers/3.1b_Discussion\%20Paper_Australia.doc. The Equal Value of All Human Life? Consider this statement by Pope John Paul II: ‘‘As far as the right to life is concerned, every innocent human being is absolutely equal to all others. . . . Before the moral norm which prohibits the direct taking of the life of an innocent human being there are no privileges or exceptions for anyone. It makes no difference whether one is the master of the world or the ‘poorest of the poor’ on the face of the earth. Before the demands of morality we are all absolutely equal.’’ 6 This represents a widely held ethical position, not merely the position of a religious leader or of someone with a Christian or, more specifically, a Roman Catholic viewpoint. It expresses a kind of ‘‘official morality’’ that is often applied in statements about people with cognitive disabilities. Most people pay lip service to it, though I’m not sure how many really hold it when it comes to the crunch. I will argue that this doctrine cannot be sustained in the light of the facts that I have been referring to—or at least not without a very drastic revision to aspects of our morality, which most people don’t want to make. Here is the problem: Can we justify attributing equal value to all human lives, while at the same time attributing to human life a value that is superior to all animal life? Of course Pope John Paul II’s statement does not say, ‘‘All human life is absolutely equal but all humans are superior to animals,’’ but obviously that is implied by the statement, and by the fact that while popes very frequently denounce abortion and euthanasia, no pope has yet denounced the unnecessary killing of animals for food, although such killing takes place on a vastly larger scale than abortion and euthanasia. (The number of animals killed for food each year is in the tens of billions, vastly greater than the entire human population of the planet, and that does not include fish and other marine creatures.) Clearly, Pope John Paul II and those who accept his position on this issue think not only that all humans are equal to each other but also that they are far superior to nonhuman animals. The philosophical problem is whether we can justify that view. In what follows, I briefly discuss three general attempts to ground such a view, dividing them into three categories: religious, speciesist, and those that depend on cognitive abilities. Religious Grounds As Pope John Paul II’s statement indicates, obviously there is a variety of religious grounds upon which people might attempt to justify the doctrine of both the equal worth of all human life and human superiority over 6 John Paul II, Evangelium Vitae, 1995. r 2009 The Author Journal compilation r 2009 Metaphilosophy LLC and Blackwell Publishing Ltd SPECIESISM AND MORAL STATUS 571 nonhuman animals. For example, religious grounds might include the following: 1. We are made in the image of God, and animals are not. 2. God gave us dominion over animals. 3. We have immortal souls, and animals do not. I do not think there is any good evidence for any of these claims. I regard them all as false. Some people may believe that these are true claims. I would argue, however, that even if they are true, such claims should not be the basis of law or public policy in a society that is not based on a religious creed or religious profession. The desirability of keeping church and state separate is sufficient basis for saying that even those who accept these religious claims should agree that in a pluralist society they should not suffice for making laws that regulate how we treat human beings and nonhuman animals. Speciesist Grounds I use the term ‘‘speciesism’’ deliberately, to make a parallel with other ‘‘isms’’ that we are familiar with, particularly racism and sexism. There are a number of arguments that fall into this general category. Sometimes they are made by quite respectable philosophers—for example, Bernard Williams, who defends the view that since we humans are doing the judging, we are entitled to prefer our own kind. 7 In response to an example in his article about an imaginary situation in which humans are being conquered by aliens, and the aliens defend their conquest by claiming, truthfully, that they are intellectually superior to us and have better, richer, and fuller lives than we do, Williams replies that if any human accepted such an argument, we could respond by saying simply, ‘‘Whose side are you on?’’ Williams then applies this to the case of animals, arguing that we are entitled simply to say, ‘‘We’re humans here, we’re the ones doing the judging; you can’t really expect anything else but a bias or prejudice in favor of human beings.’’ This seems to me to be a very dangerous way to argue, precisely because of the parallel to which I adverted above. I do not see that the argument is really different from a white racist saying, when it comes to a question about how one should treat people of different races, ‘‘Well, whose side are you on? We’re the ones doing the judging here, why don’t we simply prefer our kind because it is our kind?’’ We cannot claim that biological commonality entitles us to superior status over those who are not members of our species. In the case of 7 Bernard Williams, ‘‘The Human Prejudice,’’ which appears, along with a response from me, in Peter Singer Under Fire, edited by Jeffrey Schaler (Chicago: Open Court, forth- coming). r 2009 The Author Journal compilation r 2009 Metaphilosophy LLC and Blackwell Publishing Ltd PETER SINGER572 applying this to people with severe and profound cognitive disabilities, there is also a problem about saying who the ‘‘we’’ are. What is really important about saying ‘‘us?’’ Is it that we are all capable of under- standing language, and perhaps even rational argument? In that case, I am not addressing those who are profoundly mentally retarded. Or is it that I am addressing all those who are members of my species? I think it is much more important that the ‘‘we’’ of this statement are beings of at least a certain level of cognitive ability. So, if it happens that one of you is an alien who has cleverly disguised yourself in a human shape, but you are capable of understanding this argument, I am talking to you just as I am talking to members of my own species. In important respects, I have much more in common with you than I do with someone who is of my species but, because he or she is profoundly mentally retarded, has no capacity for verbal communication with me at all. In other words, if we take Williams’s question ‘‘Whose side are you on?’’ to refer to being on the side of those who share our species membership (as he presumably intended it), it is a bad argument. If on the other hand we take it to refer to being on the side of those capable of sharing in discussions of right and wrong, it clearly does not support the claim that all humans are equal. There is another claim that one often hears: that humans and no others have intrinsic worth and dignity, and that is why humans have superior status. This is really just a piece of rhetoric unless it is given some support. What is it about human beings that gives them moral worth and dignity? If there is no good answer forthcoming, this talk of intrinsic worth and dignity is just speciesism in nicer terms. I do not see any argument in the claim that merely being a member of the species Homo sapiens gives you moral worth and dignity, whereas being a member of the species Pan troglodytes (chimpanzees) does not give you worth and dignity. Some- thing more would need to be said. Superior Cognitive Abilities Some have attempted to justify superior moral status for humans on the basis that humans have superior cognitive abilities. Many people refer to Immanuel Kant’s moral philosophy as providing justification for the claims that human beings are ends in themselves, and that humans have both worth and dignity, while animals do not. In Kant’s view, ‘‘Animals are not self-conscious and are there merely as a means to an end. That end is man.’’ 8 Kant’s argument for why human beings are ends-in-themselves is that they are autonomous beings, which, in terms of Kantian philoso- phy, means that they are capable of reasoning. Note that Kant goes from defending the value of autonomy or self-consciousness to maintaining 8 Immanuel Kant, Lectures on Ethics, translated by Louis Infield (New York: Harper Torchbooks, 1963), p. 239. r 2009 The Author Journal compilation r 2009 Metaphilosophy LLC and Blackwell Publishing Ltd SPECIESISM AND MORAL STATUS 573 that ‘‘man’’ is the end. If we really take his argument seriously it means that human beings who are not self-conscious—because perhaps they are so profoundly mentally retarded that they lack self-consciousness or self- awareness— are also merely means to an end, that end being autonomous or self-conscious beings. So the Kantian approach is not going to help those whose objective is to demonstrate that all human beings have superior status to nonhuman animals. Those who see morality as a social contract are also likely to link moral status to higher cognitive capacities. According to this view, the core of morality is that I agree not to harm you, in return for your agreement not to harm me. 9 Some cognitive abilities are required to be capable of forming and adhering to an agreement of this kind. If you are profoundly mentally retarded, you may not have those abilities. You certainly are not likely to have them to an extent that is superior to that of some nonhuman animals, who have been shown to be capable of reciprocity. As with the Kantian argument, therefore, a contractarian account of morality is unable to justify granting all humans a moral status superior to that of any nonhuman animal, though it may justify granting some humans a moral status superior to that of some humans and of any nonhuman animal. So to reiterate: because of the overlap in cognitive ability between some humans and some nonhuman animals, attempts to draw a moral line on the basis of cognitive ability, as Kant and the contractarians try to do, will require either that we exclude some humans—for example, those who are profoundly mentally retarded—or that we include some nonhu- man animals—those whose levels of cognitive ability are equal or superior to the lowest level found in human beings. Hence we have to conclude that the standard ethical view that we find expressed in the statement by John Paul II—the view that all human beings, irrespective of their cognitive abilities, have equal moral status, and that this status is superior to the moral status of the most intelligent nonhuman animals—cannot be defended. We find ourselves in need of an alternative to the status quo. An Alternative View There are a number of possible alternatives to the view that all human life is of equal value, and this value is superior to that of any nonhuman animals. We could: 1. preserve equality by raising the status of animals, granting them the same status we now grant to humans; or 9 The social contract view can be found in ancient Greece, for example in the position of Glaucon, as represented in Plato’s Republic. Its most famous exponents are Thomas Hobbes, John Locke, and Jean-Jacques Rousseau, and in our own era, John Rawls and David Gauthier. r 2009 The Author Journal compilation r 2009 Metaphilosophy LLC and Blackwell Publishing Ltd PETER SINGER574 2. preserve equality by lowering the status of humans to that which we now grant to animals; or 3. abandon the idea of the equal value of all humans, replacing that with a more graduated view in which moral status depends on some aspects of cognitive ability, and that graduated view is applied both to humans and nonhumans. I assume that we can all agree in rejecting (2). I am to some extent sympathetic to (1) but not in every respect. Alternative (3) remains a possibility; let us consider how we might go in that direction. Long before most people were contemplating any serious degree of concern for animals, Jeremy Bentham, the founding father of the English school of Utilitarianism, wrote, ‘‘The question is not, ‘Can they reason?’ nor, ‘Can they talk?’ but, ‘Can they suffer?’’’ 10 That is indeed a crucial question to ask whenever we are talking about beings who are capable of suffering and one that is clearly relevant to how we should treat both humans and nonhuman animals. Can they suffer? Can they enjoy life? If so, they have interests that we should take into account, and we should give those interests equal weight with the interests of all other beings with similar interests. We should not discount their interests in not suffering because they cannot talk or because they are incapable of reasoning; and we should not discount their interests in enjoying life, in having things that are fulfilling and rewarding for them, either. The principle of equal consideration of interests should apply to both humans and animals. That’s the sense in which I want to elevate animals to the moral status of humans. I imagine that many people who care for profoundly mentally retarded humans would support Bentham’s idea that the ability to talk or to reason is irrelevant to the importance of avoiding suffering and facilitat- ing an enjoyable life. But Bentham’s principle many not apply to all aspects of human or animal life. Consider a comment from Roger Scruton, a conservative British philosopher who defends the killing and eating of animals, although only if they are well treated during their life and not, for example, reared on modern intensive farms. Killing animals is not, Scruton says, wrong in itself, because ‘‘there is a real distinction, for a human being, between timely and untimely death. To be ‘cut short’ before one’s time is a waste—even a tragedy. . . . No such thoughts apply to domestic cattle. To be killed at thirty months is not intrinsically more tragic than to be killed at forty, fifty, or sixty.’’ 11 One of the reasons Scruton thinks that ‘‘untimely death’’ is a tragedy for a human being is that if a human being is killed before his or her time 10 Jeremy Bentham, Introduction to the Principles of Morals and Legislation (1789), chap. 17. 11 Roger Scruton, ‘‘The Conscientious Carnivore,’’ in Food for Thought, edited by Steve Sapntzis (Amherst, N.Y.: Prometheus, 2004), pp. 81–91; the passage quoted is on p. 88. r 2009 The Author Journal compilation r 2009 Metaphilosophy LLC and Blackwell Publishing Ltd SPECIESISM AND MORAL STATUS 575 there are likely to be achievements that this human being may have accomplished which he or she will not accomplish. So, if you like, there is a failure to carry out plans that had been made, and to achieve what the person wanted to achieve. Cattle, on Scruton’s view, have no plans for the future, and no accomplishments that they would have achieved, had they been able to live long longer. We could debate this factual claim, but I accept the normative view that there is greater significance in killing a being who has plans for the future—who wishes to accomplish things— than there is in killing a being who is incapable of thinking about the future at all but exists either moment to moment or within a very short- time horizon (for example, a time horizon limited to thinking about eating something in the near future). It is, other things being equal, much less a tragedy to kill that sort of being than to kill someone who wants to live long enough to do the sorts of things that humans typically want to achieve over the course of their lives. But, of course, if this reason is invoked to justify killing well-treated animals for food, then this has implications for the question of whether one can justify ending the life of a profoundly cognitively disabled human being. One could, after all, rewrite Scruton’s statement as follows: ‘‘There is a real distinction, for a cognitively normal human being, between timely and untimely death. To be ‘cut short’ before one’s time is a waste—even a tragedy. . . . No such thoughts apply to a being unable to make plans for the future. For such a being, to be killed at an early age is not intrinsically more tragic than to die in old age.’’ Of course, this challenges a widely accepted human ethic. So if you thought that Scruton provided you with a sound justification for continuing to enjoy steak for dinner (as long as you get humanely raised, grass-bred beef), you need to think whether you are prepared to accept the argument in a nonspeciesist way and apply it to all beings who are unable to make plans for the future. That there is some significance, as far as the wrongness of killing is concerned, in whether the being killed can think about the future, seems to me defensible. How much significance there is in this is a more … 1 THE CHALLENGE OF CULTURAL RELATIVISM by JAMES RACHELS “Morality differs in every society, and is a convenient term for socially approved habits.” Ruth Benedict, Patterns of Culture (1934) 2.1 How Different Cultures Have Different Moral Codes Darius, a king of ancient Persia, was intrigued by the variety of cultures he encountered in his travels. He had found, for example, that the Callatians (a tribe of Indians) customarily ate the bodies of their dead fathers. The Greeks, of course, did not do that—the Greeks practiced cremation and regarded the funeral pyre as the natural and fitting way to dispose of the dead. Darius thought that a sophisticated understanding of the world must include an appreciation of such differences between cultures. One day, to teach this lesson, he summoned some Greeks who happened to be present at his court and asked them what they would take to eat the bodies of their dead fathers. They were shocked, as Darius knew they would be, and replied that no amount of money could persuade them to do such a thing. Then Darius called in some Callatians, and while the Greeks listened asked them what they would take to burn their dead fathers bodies. The Callatians were horrified and told Darius not even to mention such a dreadful thing. This story, recounted by Herodotus in his History illustrates a recurring theme in the literature of social science: Different cultures have different moral codes. What is thought right within one group may be utterly abhorrent to the members of another group, and vice versa. Should we eat the bodies of the dead or burn them? If you were a Greek, one answer would seem obviously correct; but if you were a Callatian, the opposite would seem equally certain. It is easy to give additional examples of the same kind. Consider the Eskimos. They are a remote and inaccessible people. Numbering only about 25,000, they live in small, isolated settlements scattered mostly along the northern fringes of North America and Greenland. Until the beginning of the 20th century, the outside world knew little about them. Then explorers began to bring back strange tales. Eskimos customs turned out to be very different from our own. The men often had more than one wife, and they would share their wives with guests, lending them for the night as a sign of hospitality. Moreover, within a community, a dominant male might demand and get regular sexual access to other mens wives. The women, however, were free to break these arrangements simply by leaving their husbands and taking up with new partners—free, that is, so long as their former husbands 2 chose not to make trouble. All in all, the Eskimo practice was a volatile scheme that bore little resemblance to what we call marriage. But it was not only their marriage and sexual practices that were different. The Eskimos also seemed to have less regard for human life. Infanticide, for example, was common. Knud Rasmussen, one of the most famous early explorers, reported that be met one woman who bad borne 20 children but had killed 10 of them at birth. Female babies, he found, were especially liable to be destroyed, and this was permitted simply at the parents discretion, with no social stigma attached to it. Old people also, when they became too feeble to contribute to the family, were left out in the snow .to die. So there seemed to be, in this society, remarkably little respect for life. To the general public, these were disturbing revelations. Our own way of living seems so natural and right that for many of us it is hard to conceive of others living so differently. And when we do hear of such things, we tend immediately to categorize those other peoples as backward or primitive. But to anthropologists and sociologists, there was nothing particularly surprising about the Eskimos. Since the time of Herodotus, enlightened observers have been accustomed to the idea that conceptions of right and wrong differ from culture to culture. If we assume that our ideas of right and wrong will be shared by all peoples as all times, we are merely naive. 2.2 Cultural Relativism To many thinkers, this observation—Different cultures have different moral codes— has seemed to be the key to understanding morality. The idea of universal truth in ethics, they say, is a myth. The customs of different societies are all that exist. These customs cannot be said to be correct or incorrect, for that implies we have an independent standard of right and wrong by which they may be judged. But there is no such independent standard; every standard is culture-bound. The great pioneering sociologist William Graham Sumner, writing in 1906, put the point like this: The right way is the way which the ancestors used and which has been handed down. The tradition is its own warrant. It is not held subject to verification by experience. The notion of right is in the folkways. It is not outside of them, of independent origin, and brought to test them. In the folkways, whatever is, is right. This is because they are traditional, and therefore contain in themselves the authority of the ancestral ghosts. When we come to the folkways we are at the end of our analysis. 3 This line of thought has probably persuaded more people to be skeptical about ethics than any other single thing. Cultural Relativism, as it has been called, challenges our ordinary belief in the objectivity and universality of moral truth. It says, in effect, that there is not such thing as universal truth in ethics; there are only the various cultural codes, and nothing more. Moreover, our own code has no special status; it is merely one among many. As we shall see, this basic idea is really a compound of several different thoughts. It is important to separate the various elements of the theory because, on analysis, some parts turn out to be correct, while others seem to be mistaken. As a beginning, we may distinguish the following claims, all of which have been made by cultural relativists: 1. Different societies have different moral codes. 2. There is no objective standard that can be used to judge one societal code better than another. 3. The moral code of our own society has no special status; it is merely one among many. 4. There is no universal truth in ethics; that is, there are no moral truths that hold for all peoples at all times. 5. The moral code of a society determines what is right within that society; that is, if the moral code of a society says that a certain action is right, then that action is right, at least within that society. 6. It is mere arrogance for us to try to judge the conduct of other peoples. We should adopt an attitude of tolerance toward the practices of other cultures. Although it may seem that these six propositions go naturally together, they are independent of one another, in the sense that some of them might be false even if others are true. In what follows, we will try to identify what is correct in Cultural Relativism, but we will also be concerned to expose what is mistaken about it. 2.3 The Cultural Differences Argument Cultural Relativism is a theory about the nature of morality. At first blush it seems quite plausible. However, like all such theories, it may be evaluated by subjecting it to rational analysis; and when we analyze Cultural Relativism we find that it is not so plausible as it first appears to be. The first thing we need to notice is that at the heart of Cultural Relativism there is a certain form of argument. The strategy used by cultural relativists is to argue from facts about the differences between cultural 4 outlooks to a conclusion about the status of morality. Thus we are invited to accept this reasoning: 1. The Greeks believed it was wrong to eat the dead, whereas the Callatians believed it was right to eat the dead. 2. Therefore, eating the dead is neither objectively fight nor objectively wrong. It is merely a matter of opinion, which varies from culture to culture. Or, alternatively: 1. The Eskimos see nothing wrong with infanticide, whereas Americans believe infanticide is immoral. 2. Therefore, infanticide is neither objectively right nor objectively wrong. It is merely a matter of opinion, which varies from culture to culture. Clearly, these arguments are variations of one fundamental idea They are both special cases of a more general argument, which says: 1. Different cultures have different moral codes. 2. Therefore, there is no objective truth in morality. Right and wrong are only matters of opinion, and opinions vary from culture to culture. We may call this the Cultural Differences Argument. To many people, it is persuasive. But from a logical point of view, is it sound? It is not sound. The trouble is that the conclusion does not follow from the premise— that is, even if the premise is true, the conclusion still might be false. The premise concerns what people believe. In some societies, people believe one thing; in other societies, people believe differently. The conclusion, however, concerns what really is the case. The trouble is that this sort conclusion does not follow logically from this sort of premise. Consider again the example of the Greeks and Callatians. The Greeks believed it was wrong to eat the dead; the Callatians believed it was right. Does it follow, from the mere fact that they disagreed, that there is no objective truth in the matter? No, it does not follow; for it could be that the practice was objectively right (or wrong) and that one or the other of them was simply mistaken. To make the point clearer, consider a different matter In some societies, people believe the earth is flat In other societies, such as our own, 5 people believe the earth is (roughly) spherical. Does it follow, from the mere fact that people disagree, that there is no objective truth in geography? Of course not; we would never draw such a conclusion because we realize that, in their beliefs about the world, the members of some societies might simply be wrong. There is no reason to think that if the world is round everyone must know it. Similarly, there is no reason to think that if there is moral truth everyone must know it. The fundamental mistake in the Cultural Differences Argument is that it attempts to derive a substantive conclusion about a subject from the mere fact that people disagree about it. This is a simple point of logic, and it is important not to misunderstand it. We are not saying (not yet, anyway) that the conclusion of the argument is false. It is still an open question whether the conclusion is true or false. The logical point is just that the conclusion does not follow from the premise. This is important, because in order to determine whether the conclusion is true, we need arguments in its support. Cultural Relativism proposes this argument, but unfortunately the argument turns out to be fallacious. So it proves nothing. 2.4 The Consequences of Taking Cultural Relativism Seriously Even if the Cultural Differences Argument is invalid, Cultural Relativism might still be true. What would it be like if it were true? In the passage quoted above, William Graham Sumner summarizes the essence of Cultural Relativism. He says that there is no measure of right and wrong other than the standards of ones society: The notion of right is in the folkways. It is not outside of them, of independent origin, and brought to test them. In the folkways, whatever is, is right. Suppose we took this seriously. What would be some of the consequences? 1. We could no longer say that the customs of other societies are morally inferior to our own. This, of course, is one of the main points stressed by Cultural Relativism. We would have to stop condemning other societies merely because they are different: So long as we concentrate on certain examples, such as the funerary practices of the Greeks and Callatians, this may seem to be a sophisticated, enlightened attitude. However, we would also be stopped from criticizing other, less benign practices. Suppose a society waged war on its neighbors for the purpose of taking slaves. Or suppose a society was violently anti-Semitic and its leaders set out to destroy the Jews. Cultural Relativism would preclude us from saying that either of these practices was wrong. We would not even be able to say that a society tolerant of Jews is better than the anti- Semitic society, for that would imply some sort of transcultural standard of comparison. The failure to condemn these practices does not seem 6 enlightened; on the contrary, slavery and anti-Semitism seem wrong wherever they occur. Nevertheless, if we took Cultural Relativism seriously, we would have to regard these social practices as also immune from criticism. 2. We could decide whether actions are right or wrong just by consulting the standards of our society. Cultural Relativism suggests a simple test for determining what is right and what is wrong: All one need do is ask whether the action is in accordance with the code of ones society. Suppose in 1975, a resident of South Africa was wondering whether his countrys policy of apartheid—a rigidly racist system—was morally correct. All he has to do is ask whether this policy conformed to his societys moral code. If it did, there would have been nothing to worry about, at least from a moral point of view. This implication of Cultural Relativism is disturbing because few of us think that our societys code is perfect; we can think of ways it might be improved. Yet Cultural Relativism would not only forbid us from criticizing the codes of other societies; it would stop us from criticizing our own. After all, if right and wrong are relative to culture, this must be true for our own culture just as much as for other cultures. 3. The idea of moral progress is called into doubt. Usually, we think that at least some social changes are for the better. (Although, of course, other changes may be for the worse.) Throughout most of Western history the place of women in society was narrowly circumscribed. They could not own property; they could not vote or hold political office; and generally they were under the almost absolute control of their husbands. Recently much of this has changed, and most people think of it as progress. If Cultural Relativism is correct, can we legitimately think of this as progress? Progress means replacing a way of doing things with a better way. But by what standard do we judge the new ways as better? If the old ways were in accordance with the social standards of their time, then Cultural Relativism would say it is a mistake to judge them by the standards of a different time. Eighteenth-century society was, in effect, a different society from the one we have now. To say that we have made progress implies a judgment that present-day society is better, and that is just the sort of transcultural judgment that, according to Cultural Relativism, is impermissible. Our idea of social reform will also have to be reconsidered. Reformers such as Martin Luther King, Jr., have sought to change their societies for the better. Within the constraints imposed by Cultural Relativism, there is one way this might be done. If a society is not living up to its own ideals, the reformer may be regarded as acting for the best: The ideals of the 7 society are the standard by which we judge his or her proposals as worthwhile. But the reformer may not challenge the ideals themselves, for those ideals are by definition correct. According to Cultural Relativism, then, the idea of social reform makes sense only in this limited way. These three consequences of Cultural Relativism have led many thinkers to reject it as implausible on its face. It does make sense, they say, to condemn some practices, such as slavery and anti-Semitism, wherever they occur. It makes sense to think that our own society has made some moral progress, while admitting that it is still imperfect and in need of reform. Because Cultural Relativism says that these judgments make no sense, the argument goes, it cannot be right. 2.5 Why There Is Less Disagreement Than It Seems The original impetus for Cultural Relativism comes from the observation that cultures differ dramatically in their views of right and wrong. But just how much do they differ? It is true that there are differences. However, it is easy to overestimate the extent of those differences, Often, when we examine what seems to be a dramatic difference, we find that the cultures do not differ nearly as much as it appears. Consider a culture in which people believe it is wrong to eat cows. This may even be a poor culture, in which there is not enough food; still, the cows are not to be touched. Such a society would appear to have values very different from our own. But does it? We have not yet asked why these people will not eat cows. Suppose it is because they believe that after death the souls of humans inhabit the bodies of animals, especially cows, so that a cow may be someones grandmother. Now do we want to say that their values are different from ours? No; the difference lies elsewhere. The difference is in our belief systems, not in our values. We agree that we shouldnt eat Grandma; we simply disagree about whether the cow is (or could be) Grandma. The point is that many factors work together to produce the customs of a society. The societys values are only one of them. Other matters, such as the religions and factual beliefs held by its members, and the physical circumstances in which they must live, are also important. We cannot conclude, then, merely because customs differ, that there is a disagreement about values. The difference in customs may be attributable to some other aspects of social life. Thus there may be less disagreement about values than there appears to be. Consider again the Eskimos, who often kill perfectly normal infants, especially girls. We do not approve of such things; a parent who killed a baby in our society would be locked up. Thus there appears to be a great difference in the values of our two cultures. But suppose we ask 8 why the Eskimos do this. The explanation is not that they have less affection for their children or less respect for human life. An Eskimo family will always protect its babies if conditions permit. But they live in a harsh environment, where food is in short supply. A fundamental postulate of Eskimos thought is: Life is hard, and the margin of safety small.” A family may want to nourish its babies but be unable to do so. As in many primitive societies, Eskimo mothers will nurse their infants over a much longer period of time than mothers in our culture. The child will take nourishment from its mothers breast for four years, perhaps even longer. So even in the best of times there are limits to the number of infants that one mother can sustain. Moreover, the Eskimos are a nomadic people—unable to farm, they must move about in search of food. Infants must be carried, and a mother can carry only one baby in her parka as she travels and goes about her outdoor work. Other family members help whenever they can. Infant girls are more readily disposed of because, first, in this society the males are the primary food providers—they are the hunters, according to the traditional division of labor—and it is obviously important to maintain a sufficient number of food providers. But there is an important second reason as well. Because the hunters suffer a high casualty rate, the adult men who die prematurely far outnumber the women who die early. Thus if male and female infants survived in equal numbers, the female adult population would greatly outnumber the male adult population. Examining the available statistics, one writer concluded that were it not for female infanticide…there would be approximately one-and-a-half times as many females in the average Eskimo local group as there are food-producing males. So among the Eskimos, infanticide does not signal a fundamentally different attitude toward children. Instead, it is a recognition that drastic measures are sometimes needed to ensure the familys survival. Even then, however, killing the baby is not the first option considered. Adoption is common; childless couples are especially happy to take a more fertile couples surplus. Killing is only the last resort. I emphasize this in order to show that the raw data of the anthropologists can be misleading; it can make the differences in values between cultures appear greater than they are. The Eskimos values are not all that different from our values. It is only that life forces upon them choices that we do not have to make. 9 2.6 How All Cultures Have Some Values in Common It should not be surprising that, despite appearances, the Eskimos are protective of their children. How could it be otherwise? How could a group survive that did not value its young? It is easy to see that, in fact, all cultural groups must protect their infants: 1. Human infants are helpless and cannot survive if they are not given extensive care for a period of years. 2. Therefore, if a group did not care for its young, the young would not survive, and the older members of the group would not be replaced. After a while the group would die out. 3. Therefore, any cultural group that continues to exist must care for its young. infants that are not cared for must be the exception rather than the rule. Similar reasoning shows that other values must be more or less universal. Imagine what it would be like for a society to place no value at all on truth telling. When one person spoke to another, there would be no presumption at all that he was telling the truth for he could just as easily be speaking falsely. Within that society, there would be no reason to pay attention to what anyone says. (I ask you what time it is, and you say Four oclock: But there is no presumption that you are speaking truly; you could just as easily have said the first thing that came into your head. So I have no reason to pay attention to your answer; in fact, there was no point in my asking you in the first place.) Communication would then be extremely difficult, if not impossible. And because complex societies cannot exist without communication among their members, society would become impossible. It follows that in any complex society there must be a presumption in favor of truthfulness. There may of course be exceptions to this rule: There may be situations in which it is thought to be permissible to lie. Nevertheless, there will be exceptions to a rule that is in force in the society. Here is one further example of the same type. Could a society exist in which there was no prohibition on murder? What would this be like? Suppose people were free to kill other people at will, and no one thought there was anything wrong with it. In such a society, no one could feel secure. Everyone would have to be constantly on guard. People who wanted to survive would have to avoid other people as much as possible. This would inevitably result in individuals trying to become as self-sufficient as possible— after all, associating with others would be dangerous. Society on any large scale would collapse. Of course, people might band together in smaller groups with others that they could trust not to harm them. But notice what this means: They would be forming 10 smaller societies that did acknowledge a rule against murder: The prohibition of murder, then, is a necessary feature of all societies. There is a general theoretical point here, namely, that there are some moral rules that all societies will have in common, because those rules are necessary for society to exist. The rules against lying and murder are two examples. And in fact, we do find these rules in force in all viable cultures. Cultures may differ in what they regard as legitimate exceptions to the rules, but this disagreement exists against a background of agreement on the larger issues. Therefore, it is a mistake to overestimate the amount of difference between cultures. Not every moral rule can vary from society to society. 2.7 Judging a Cultural Practice to Be Undesirable In 1996, a 17-year-old girl named Fauziya Kassindja arrived at Newark International Airport and asked for asylum. She had fled her native country of Togo, a small west African nation, to escape what people there call excision. Excision is a permanently disfiguring procedure that is sometimes called female circumcision, although it bears little resemblance to the Jewish ritual. More commonly, at least in Western newspapers, it is referred to as genital mutilation. According to the World Health Organization, the practice is widespread in 26 African nations, and two million girls each year are excised. In some instances, excision is part of an elaborate tribal ritual, performed in small traditional villages, and girls look forward to it because it signals their acceptance into the adult world. In other instances, the practice is carried out by families living in cities on young women who desperately resist. Fauziya Kassindja was the youngest of five daughters in a devoutly Muslim family. Her father, who owned a successful trucking business, was opposed to excision, and he was able to defy the tradition because of his wealth. His first four daughters were married without being mutilated. But when Fauziya was 16, he suddenly died. Fauziya then came under the authority of his father, who arranged a marriage for her and prepared to have her excised. Fauziya was terrified, and her mother and oldest sister helped her to escape. Her mother, left without resources, eventually had to formally apologize and submit to the authority of the patriarch she had offended. Meanwhile, in America, Fauziya was imprisoned for two years while the authorities decided what to do with her. She was finally granted asylum, but not before she became the center of a controversy about how foreigners should regard the cultural practices of other peoples. A series of articles in the New York Times encouraged the idea that excision is a barbaric practice that should be condemned. Other observers were 11 reluctant to be so judgmental—live and let live, they said; after all, our practices probably seem just as strange to them. Suppose we are inclined to say that excision is bad. Would we merely be applying the standards of our own culture? If Cultural Relativism is correct, that is all we can do, for there is no cultural-neutral moral standard to which we may appeal. Is that true? Is There a Culture-Neutral Standard of Right and Wrong? There is, of course, a lot that can be said against the practice of excision. Excision is painful and it results in the permanent loss of sexual pleasure. Its short-term effects include hemorrhage, tetanus, and septicemia. Sometimes the woman dies. Longterm effects include chronic infection, scars that hinder walking, and continuing pain. Why, then, has it become a widespread social practice? It is not easy to say. Excision has no obvious social benefits. Unlike Eskimo infanticide, it is not necessary for the groups survival. Nor is it a matter of religion. Excision is practiced by groups with various religions, including Islam and Christianity, neither of which commend it. Nevertheless, a number of reasons are given in its defense. Women who are incapable of sexual pleasure are said to be less likely to be promiscuous; thus there will be fewer unwanted pregnancies in unmarried women. Moreover, wives for whom sex is only a duty are less likely to be unfaithful to their husbands; and because they will not be thinking about sex, they will be more attentive to the needs of their husbands and children. Husbands, for their part, are said to enjoy sex more with wives who have been excised. (The womens own lack of enjoyment is said to be unimportant.) Men will not want unexcised women, as they are unclean and immature. And above all, it has been done since antiquity, and we may not change the ancient ways. It would be easy, and perhaps a bit arrogant, to ridicule these arguments. But we may notice an important feature of this whole line of reasoning: it attempts to justify excision by showing that excision is beneficial— men, women, and their families are all said to be better off when women are excised. Thus we might approach this reasoning, and excision itself, by asking which is true: Is excision, on the whole, helpful or harmful? Here, then, is the standard that might most reasonably be used in thinking about excision: We may ask whether the practice promotes or hinders the welfare of the people whose lives are affected by it. And, as a corollary, we may ask if there is an alternative set of social 12 arrangements that would do a better job of promoting their welfare. If so, we may conclude that the existing practice is deficient. But this looks like just the sort of independent moral standard that … Midterm Exam Study Guide PHI 312: Bioethics | Fall 2018 Due date: Friday, October 12 by midnight Instructions: Your final exam will take place on Canvas. You will receive five questions to answer, each chosen from the questions below. Each question will be worth 20 percent of your final exam. You are welcome to study for the exam with classmates, but all answers must be your own. Any student who submits an answer that is the same as another student’s will receive a zero on the exam. Because you will have plenty of time to study and prepare your answers, I expect them to be clear, concise, and accurate. Each question can be answered in one to two paragraphs. Although there is no word limit, you only want to include the information that is absolutely necessary. Superfluous information gives the impression that you don’t know what is important to the answer and is as harmful to your grade as missing information. I am grading you not only on accuracy, but also on whether you understand what information is important and what information is not. Do not cite or refer to any material we have not covered in class. Doing so will result in a zero. Possible Exam Questions 1. The Cultural Differences Argument is an argument about metaethics. What is the Cultural Differences Argument? Why does the argument fail? Be specific–use an example. 2. Respect for autonomy is one bioethical principle. What is autonomy? Does everyone have the same autonomy? What other moral obligations does respect for autonomy give us? 3. The principles of beneficence and nonmaleficence are also important for medical ethics. What moral guidance do the principles give us? How are they different? Finally, how can they conflict with the principle of autonomy? 4. Theories of moral status underly many of our common moral judgements. According to Singer and McMahan, the common theory of moral status has two problems: the separation problem and the equality problem. What is the common theory of moral status? What property/properties does the common theory of moral status take to be relevant for moral status? People don’t explicitly endorse a theory of moral status, so how can we tell that most people are committed to a view like this? 5. What is the separation problem? What is the equality problem? Why does the common theory of moral status lead to these two problems? How does Singer think we have to respond to these problems? 6. What, according to Singer, is speciesism? How is it like sexism or racism? What theory of moral status does Singer endorse instead of speciesism, and what are the main differences between species and Singer’s view? 7. Velleman relies on the Kantian notion of dignity to inform his position on the ethics of suicide and euthanasia. What is dignity, according to Velleman? How is it connected to theories of moral status? Which theory of moral status is it most closely connected to? 8. Which theories of moral status are most conducive to a pro-life position? Which theories of moral status are most conducive to a pro-choice position? Why? 9. Explain JJ Thomson’s account of the right to life. What is the right to life? How does this account of the right to life undermine pro-life theories of the ethics of abortion, according to Thomson? 10. Thomson’s approach to the ethics of abortion implies that sometimes abortion is bad but not unjust/wrong, and that sometimes abortion is unjust/wrong. When is abortion bad but not wrong, according to Thomson? When is abortion unjust/ wrong, according to Thomson? 11. Thomson argues that in principle one could believe that abortion is wrong because it is a rights-violation, but that abortion is permissible in cases of rape. However, this position is hard to defend. Why does Thomson think that this position is implausible? 12. Marquis thinks that the abortion debate has resulted in a stalemate. Why, argumentatively speaking, have we arrived at a stalemate in Marquis’s view? How does Marquis think we can break the stalemate? 13. Explain Don Marquis’s theory of the wrongness of killing. How does this support the pro-life view of abortion? Why is Marquis’s theory compatible with the permissibility of contraception? 14. What is dignity, according to Velleman? If we have dignity, why do we not have a right to end our lives? 15. McMahan gives a conditional argument for the permissibility of active euthanasia. What is active euthanasia? Briefly reconstruct McMahan’s conditional argument. 16. McMahan argues that rational suicide is permissible. What is rational suicide? Briefly reconstruct McMahan’s argument for the permissibility of rational suicide. A Right of Self‐Termination? Author(s): J. David Velleman Source: Ethics, Vol. 109, No. 3 (April 1999), pp. 606-628 Published by: The University of Chicago Press Stable URL: http://www.jstor.org/stable/10.1086/233924 Accessed: 22-08-2016 20:58 UTC Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at http://about.jstor.org/terms JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact [email protected] The University of Chicago Press is collaborating with JSTOR to digitize, preserve and extend access to Ethics This content downloaded from 128.205.114.91 on Mon, 22 Aug 2016 20:58:06 UTC All use subject to http://about.jstor.org/terms A Right of Self-Termination?* J. David Velleman Getting cancer changed my feelings about people who smoke. I remember hearing a fellow philosopher expound, with a wave of his cigarette, on his right to choose whether to live and die smoking, or to quit and merely survive. I was just beginning a year of chemotherapy, and mere survival sounded pretty good to me. But I was the visiting speaker, and my hosts were unaware of my diagnosis. Several of them lit up after dinner as we listened to their colleague’s disquisition — they with amused familiarity, I with an outrage that surprised even me and would have baffled them, if I had dared to express it. That I didn’t dare is a cause for regret even now, ten years after the fact. One objection was already clear to me at the time. A few months with cancer had taught me that a tumor rarely invades a region smaller than an extended family. Physically, the cancer was confined to my body, but even in that re- spect it was difficult to regard as mine. The tumor cells were growing in my bone marrow, which didn’t live up to its poetic billing as the core of my being. The marrow in my bones, I discovered, was as foreign to me as the far side of the moon: it was, in a sense, my far side —unseen, insen- sate — its depth inside me being a measure of remoteness rather than intimacy. Of course, this fertile gunk in my pelvis and skull was also my sole source of blood cells, and my life depended on it. But so did the life of my sons’ father, my wife’s husband, my parents’ son, my brothers’ brother, and I was never sure who among us would suffer the greater harm if that life ran out of gunk. 606 Ethics 109 (April 1999): 606 – 628 ! 1999 by The University of Chicago. All rights reserved. 0014-1704/99/0903-0006$02.00 * Work on this article was supported by a fellowship from the National Endowment for the Humanities, and by a sabbatical leave from the College of Literature, Science, and the Arts, University of Michigan. An earlier and very different version was presented to the philosophy department and the Center for Ethics and Humanities in the Life Sciences at Michigan State University. I received helpful comments on that version from Elizabeth Anderson and Stephen Darwall, both of whom have also contributed significantly to my thinking on this subject through their published work. I also received comments from Bette Crigger and an anonymous referee for the Hastings Center Report. For comments on the present version, I am grateful to Sally Haslanger, Connie Rosati, Tamar Schapiro, and Brian Slattery. This content downloaded from 128.205.114.91 on Mon, 22 Aug 2016 20:58:06 UTC All use subject to http://about.jstor.org/terms Listening to my host laugh at his future cancer, I wondered whether he realized how many others would share it. What I would have said on their behalf, however, wouldn’t have expressed my strongest feelings, which were felt on my own behalf, in a sense that I couldn’t articulate. I was somehow offended, insulted. Watching smoke curl from the lips of people unmindful of my mortality, I felt as I probably would feel listening to anti-Semitic remarks directed at another person by a speaker unaware that I, too, was a Jew. I was witnessing an insult to a group of which I was also a member. This symposium isn’t about the right to smoke, of course; it’s about the right to die. Not surprisingly, however, these rights tend to be articulated in the same terms. A person claiming either right might describe it, for instance, as a right ‘‘to live and die in the light of . . . his own convictions about why his life is valuable and where its value lies.’’ I can’t recall whether the speaker in my story used these exact words, but I seemed to hear his voice again when I read them in the New York Review of Books, under the title ‘‘The Philosophers’ Brief.’’1 This brief had been submitted to the U.S. Supreme Court in support of a challenge to statutes outlawing physician-assisted suicide. Reading it, I once again felt a collective slight, and this time I couldn’t miss which group was being slighted. So I think that I can now explain why I was once offended by one philosopher’s defense of smoking, and the explanation leads me to re- ject The Philosophers’ defense of assisted suicide as well. As for assisted suicide itself, however, I don’t know what to think. The complexities of the issue have thus far defeated my attempts to arrive at a settled posi- tion. On the policy question posed by this symposium, then, I am neither Pro nor Con. I’m, like, Not So Fast. The principle quoted above, which would settle the issue quickly, can be derived from two broader principles. The first principle is that a person has the right to make his own life shorter in order to make it better — to make it shorter, that is, if doing so is a necessary means or consequence of making it a better life on the whole for him. The second principle is that there is a presumption in favor of deferring to a person’s judgment on the subject of his own good. Together, these principles imply that a person has the right to live and die, in particular, by his own convictions about which life would be better for him. For the smoker in my story, of course, shortening his life was not a Velleman A Right of Self-Termination? 607 1. Ronald Dworkin et al., ‘‘Assisted Suicide: The Philosophers’ Brief,’’ New York Review of Books 44 (March 27, 1997): 41– 47. The brief was submitted in the case of Washington et al. v. Glucksberg et al. Links to briefs and opinions in this case can be found on the World Wide Web at http://ethics.acusd.edu/euthanasia.html. This content downloaded from 128.205.114.91 on Mon, 22 Aug 2016 20:58:06 UTC All use subject to http://about.jstor.org/terms means of making it better but rather a likely consequence of an activity that made it better, in his opinion, despite making it shorter, too. But in most of the cases for which assisted suicide is advocated, shortening a patient’s life is intended as a means of making it better, because the continuation of the patient’s life would detract from its overall value for him.2 When the first principle is confined to this latter context, it can be rephrased as the assertion of a patient’s right to end his life on the grounds that it is no longer worth living. I think that this principle is mistaken. Before I criticize it, however, I should speak briefly to the second principle stated above, which I can accept. I think that a person’s considered judgment about his good is a judgment to which we generally ought to defer. More specifically, then, I think that we generally ought to defer to a person on the question whether his life is worth living, since the living- worthiness of a life measures the extent to which the continuation of that life would be good for the person living it. The person living a life is the best judge of the value that its continuation would afford him — not an infallible judge, of course, but usually more reliable than anyone else is likely to be. Indeed, his judgment of this value is to some extent self- fulfilling, since his merely liking or disliking aspects of his life can to some extent make them good or bad for him. The reasons for deferring to a person’s judgment about his good go beyond his reliability as a judge. Respect for a person’s autonomy may require that we defer to his considered judgment about his good even when we have reason to regard that judgment as mistaken. Letting him live his own life may sometimes entail letting him make his own mistakes about what’s good for him — including, perhaps, mistakes about whether it would be good for him to go on living. Forbidding a person to make such mistakes can be objectionably paternalistic, because it would usurp his role as the primary agent of his own affairs. Thus, if a person had the right to end his life on the grounds that it wasn’t worth living (in accordance with the first principle, above), then he would have the right to be guided by his own judgment on that score (in accordance with the second principle). But I reject the principle that a person has the right to end his life solely on the grounds of the benefits he will thereby obtain or the harms he will avoid. One reason for rejecting this principle is that a life confers benefits and harms on people other than the person living it. Does a person have the right to deprive his children of a parent simply because life isn’t worth enough to him? I want to set aside this question, however, because it tacitly concedes 608 Ethics April 1999 2. I discuss evaluations of this kind in ‘‘Well-Being and Time,’’ Pacific Philosophical Quarterly 72 (1991): 48 –77. This content downloaded from 128.205.114.91 on Mon, 22 Aug 2016 20:58:06 UTC All use subject to http://about.jstor.org/terms the assumption that the values at stake in life-or-death decisions are rela- tive to personal interests; it merely invites us to consider a wider circle of potential beneficiaries. The values that we need to consider, in my view, aren’t relative to personal interests and consequently have no bene- ficiaries. One might insist that values must have beneficiaries, because they wouldn’t exist if there weren’t someone who could appreciate them: nothing would be good or bad in a universe devoid of sentient beings.3 But the fact that values wouldn’t exist without potential valuers does not entail that they must accrue to someone. Values are relative to potential valuers because they are normative, in the first instance, for valuation.4 That is, for something to be valuable just is for it to be such as ought to be valued in some way — respected, loved, admired, wanted, treasured, or the like. The very concept of value therefore contains the concept of a valuer, actual or potential. The experience of valuing something can be beneficial, as in the case of appreciating the aesthetic value in a work of art. But the concept of value, in positing a potential valuer, doesn’t necessarily require that he would benefit from the experience. Things can be venerable, for ex- ample, whether or not there is any benefit in venerating them; and they can be awesome whether or not one would gain by holding them in awe. So the fact that value must be capable of registering with someone, who would thus appreciate it, does not mean that it must be capable of accru- ing to someone, who would thus gain by it. Value requires a potential valuer but not a potential beneficiary. In fact, our appreciation of values that are relative to the interest of a beneficiary may depend on a prior appreciation of a value that is not relational in this sense. This dependence emerges when we try to expli- cate the concept of interest-relative value, or what is good for a person. The concept of what is good for a person turns out to be fairly resistant to explication. We might initially think to equate what’s good for a per- son with whatever would be rational for him to care about. But this equa- tion would end up implying that all rational concerns are self-interested, by definition. In order to allow for the possibility of rational selflessness, we have to acknowledge that not everything that would be rational for someone to care about is necessarily in his interest. Various philosophers have therefore attempted to define what’s good for a person as a proper subset of the things that would be rational for him to care about, such as the subset including only those things Velleman A Right of Self-Termination? 609 3. See Peter Railton, ‘‘Facts and Values,’’ Philosophical Topics 14 (1986): 5 –31. 4. See Elizabeth Anderson, Value in Ethics and Economics (Cambridge, Mass.: Harvard University Press, 1993). This content downloaded from 128.205.114.91 on Mon, 22 Aug 2016 20:58:06 UTC All use subject to http://about.jstor.org/terms which require his existence. It may or may not be a drawback in these definitions that they would exclude from a person’s good such things as posthumous fame. In any case, these definitions are still too inclusive, since the things involving a person’s existence that are rational for him to care about include, for example, particular sacrifices that he can make for other people. The only convincing analysis of a person’s good, to my knowledge, is one recently proposed by Stephen Darwall, who argues that what’s good for a person is what’s rational to want for his sake.5 ‘For the sake of ’ is a phrase that marks the subordination of one concern to another: to care about one thing for the sake of something else is to care about the former out of concern for the latter. To want something for the sake of a person is thus to want it out of concern for the person himself. Darwall’s analysis says that a person’s good is what would be rational to want out of concern for that person. Darwall argues — convincingly, to my mind — that a person’s good is a rational object of desire for anyone who cares about that person. By the same token, he argues that even the person himself is rationally obliged to care about his good only insofar as he cares about the person whose good it is — that is, himself.6 Think here of the familiar connection between how you feel about yourself and how you feel about your good. Sometimes when you realize that you have done something mean spirited or shameful, you come to feel worthless as a person; you may even hate yourself; and one symptom of self-hatred is a loss of concern for your own welfare. It no longer seems to matter whether life treats you well or badly, because you yourself seem to be no good. Your desire for your good thus depends on your concern for yourself — and rationally so, according to Darwall’s analysis. Note that self-loathing isn’t the feeling that you are worthless to your- self. Indeed, the value that things afford to you is precisely what no longer seems to matter, and so your having no value for yourself wouldn’t seem to matter, either. The reason why value accruing to you no longer seems to matter, however, is just that you don’t seem to matter, period. You have lost your appreciation for the value that things have in rela- tion to your interest because you have lost a sense of embodying value in yourself. Now, things could still be good for you, in Darwall’s analysis, even if you didn’t embody any value; since they could still be such as would be ratio- nal for someone to want if he cared about you, however baseless the 610 Ethics April 1999 5. Stephen Darwall, ‘‘Self-Interest and Self-Concern,’’ Social Philosophy and Policy 14 (1997): 158 –78, reprinted in Self-Interest, ed. Ellen Paul (Cambridge: Cambridge University Press, 1997). This article is also the source for my statement of the problem in the preced- ing section. 6. The points made here and in the following paragraph appear in Anderson, p. 26. This content downloaded from 128.205.114.91 on Mon, 22 Aug 2016 20:58:06 UTC All use subject to http://about.jstor.org/terms latter concern might be. But things that were good for you would not actually merit concern unless you merited concern; and if you didn’t, then despite their being good for you, they wouldn’t ultimately be worth wanting, after all. As I put it a moment ago, what’s good for you wouldn’t matter if you didn’t matter. This account of a person’s good therefore implies — rightly, again, in my opinion — that what’s good for a person is not a categorical value, any more than what’s good for a purpose. What’s good for a purpose is worth caring about only out of concern for the purpose, and hence only insofar as the purpose is worth caring about. Similarly, what’s good for a person is worth caring about only out of concern for the person, and hence only insofar as he is worth caring about. A person’s good has only hypothetical or conditional value, which depends on the value of the person himself.7 Of course, we assume that a person’s good does matter. But we make this assumption only because we assume that people matter — that every- one has a value that makes him worth caring about. Darwall’s analysis of a person’s good reveals how our appreciation of value that accrues to someone depends on a prior appreciation of a value inhering in him. The latter value cannot be relative to personal interests, on pain of setting off a problematic regress. If this value were relative to someone’s interest, then it would matter only to the same extent as that beneficiary. This regress of values would continue until it reached a value that was not relative to anyone’s interest and that consequently mattered for its own sake. In fact, however, the regress never gets started, because we assume that every person already matters for his own sake, because of embodying an interest-independent value. A value of this kind, which a person has in himself but not for anyone, is the basis of Kantian moral theory. Kant’s term for this value is ‘dignity’, and he attributes dignity to all persons in virtue of their rational nature. What morality requires of us, according to Kant, is that we respect the dignity of persons.8 The dignity of a person is a value that differs in kind from his inter- est. Unlike his interest, for example, his dignity is a value on which his opinion carries no more weight than anyone else’s. Because this value does not accrue to him, he is in no better position to judge it than others. Similarly, respect for a person’s autonomy does not require defer- ence to him on questions of his dignity, as it does on questions of his Velleman A Right of Self-Termination? 611 7. This point, too, is made by Anderson. 8. Here I am making a leap that requires more justification than I can provide in the present context. I am equating the value that we appreciate in caring about a person with the value that we appreciate, somewhat differently, in respecting that person in the Kantian sense. I defend this equation in ‘‘Love as a Moral Emotion,’’ Ethics 109 (1999): 338 –74. This content downloaded from 128.205.114.91 on Mon, 22 Aug 2016 20:58:06 UTC All use subject to http://about.jstor.org/terms good. On the contrary, respect for a person’s autonomy just is an appre- ciation of a value in him that amounts to a dignity, in Kant’s sense of the term, precisely because it commands respect. If a person denies embody- ing such a value, he can hardly claim that we should defer to him out of an appreciation for a value such as he denies. He cannot claim, in other words, that out of respect for his autonomy we should defer to his judg- ment that he possesses nothing worthy of our respect. Nor is it paternalistic to challenge a person’s judgment about his dignity, as it is in the case of his good. Challenging a person’s judgment about his good is objectionable because it undermines his role as the agent of his own affairs; but his value as a person is not just his affair. Although his good is a value that accrues to him alone, in the first in- stance, his value as a person inheres in him among other persons. It’s a value that he possesses by virtue of being one of us, and the value of being one of us is not his alone to assess or defend. The value of being a person is therefore something larger than any particular person who embodies it. That’s what I miss in so many discussions of euthanasia and assisted sui- cide: a sense of something in each of us that is larger than any of us, something that makes human life more than just an exchange of costs for benefits, more than just a job or a trip to the mall. I miss the sense of a value in us that makes a claim on us — a value that we must live up to. I don’t deny that there are circumstances under which it would be better for one’s life to end and permissible to hasten its ending. What I deny is that one may end one’s life simply because one isn’t getting enough out of it. One has to consider whether one is doing justice to it. If a person possesses no value that he must live up to, or do justice to, then his life becomes a mere instrument, to be used or discarded according to whether it serves his interest. His moral claim to his own life then looks something like this: [A] patient’s right to life includes a right not to be killed. But that right gives [him] a protected option whether to live or die, an op- tion with which others cannot legitimately interfere; it does not give [him] a duty to live. If a patient decides to die, he is waiving his right to live. By waiving his right, he releases others (perhaps a specific other person) from a duty not to kill him. This can’t be right. It portrays morality as protecting a person’s options without protecting the person himself, except insofar as his own exis- tence is one of his options. Surely, however, options are worth protect- ing, not for their own sake, but for the sake of the person whose options they are. So how can morality treat the person as worth protecting only for the sake of protecting one of his options? If he doesn’t already merit protection, how can they? 612 Ethics April 1999 This content downloaded from 128.205.114.91 on Mon, 22 Aug 2016 20:58:06 UTC All use subject to http://about.jstor.org/terms The quotation above is drawn from a recent essay by Frances Kamm, who goes on to answer Kantian objections as follows: 9 Suppose life involves such unbearable pain that one’s whole life is focused on that pain. In such circumstances, one could, I believe, decline the honor of being a person. . . . We might acknowledge the great (and normally overriding) value of being a person . . . [and yet] allow that some bad conditions may overshadow its very great value. Here Kamm is claiming that someone can view life as a mere option even while accepting the Kantian view of his value as a person. The problem with this passage is that it misstates the Kantian view. When Kamm says that the value of a person normally ‘‘overrides’’ the value of other goods, but can be ‘‘overshadowed’’ by conditions that are exceptionally bad, she implies that it can be balanced against the person’s interest. And when she goes on to speak of this value as an ‘‘honor’’ that the person can decline, she implies that it is actually part of a person’s interest, since an honor accrues to a particular person, whose role as its beneficiary entitles him to accept or decline it. But the dignity of a person isn’t something that he can accept or decline, since it isn’t a value for him; it’s a value in him, which he can only violate or respect. Nor can it be weighed against what is good or bad for the person. As I have argued, value for a person stands to value in the person roughly as the value of means stands to that of the end: in each case, the former merits concern only on the basis of concern for the latter. And conditional values cannot be weighed against the uncondi- tional values on which they depend. The value of means to an end can- not overshadow or be overshadowed by the value of the end, because it already is only a shadow of that value, in the sense of being dependent upon it. Similarly, the value of what’s good for a person is only a shadow of the value inhering in the person, and cannot overshadow or be over- shadowed by it. These are abstract considerations, but they are concretely illustrated by the story with which I began. When my host claimed that he benefited more from the pleasures of smoking than he would be harmed by an early death, my first thought was that he had failed to consider harms and benefits to people other than himself. On second thought, however, I resented his assumption that harms and benefits were the only values at stake. My host’s remarks implied that an early death, of the sort he was risk- ing and I was hoping to forestall, would be a loss to him that could be offset Velleman A Right of Self-Termination? 613 9. Frances Kamm, ‘‘A Right to Choose Death?’’ Boston Review 22 (1997): 20 –23. This content downloaded from 128.205.114.91 on Mon, 22 Aug 2016 20:58:06 UTC All use subject to http://about.jstor.org/terms by sufficient gains. But what would it matter how much I lost or gained if I myself would be no loss? My gains or losses would merit concern only on the basis of concern for me —which, being the basis of concern for them, could not then be offset by that concern. Hence my gains or losses wouldn’t matter unless I had a value that could not be offset by theirs. My host was implicitly denying the existence of such a value. For he claimed that death was worth worrying about only in respects for which he could be compensated by the pleasures of smoking. He was thus implicitly denying the interest-independent value of a person, without which it couldn’t really matter whether I lived or died. Of course, he was denying the existence of this value in his own case, not in mine; but our cases were indistinguishable on this score. By implicitly denying his own interest-independent value, my host was somehow trivializing or denigrating himself as a person. Sometimes people’s self-denigrating remarks just embarrass us, but in other in- stances they can be sufficiently principled to give offense. Recall my ear- lier reference to anti-Semitism. Anti-Semitism can manifest itself in self- denigrating remarks, if it is the anti-Semitism of a self-hating Jew. My host’s disregard for his own value as a person offended me as another person, just as someone’s denigrating himself as a Jew would offend me as another Jew. I think Kant was right to say that trading one’s person in exchange for benefits, or relief from harms, denigrates the value of personhood, re- spect for which is a criterion of morality (Kant would say, the criterion). That’s why I think that smoking is a vice — at least, when practiced for the reasons offered by my host. It’s also why I think that suicide is im- moral when committed on the grounds that life isn’t worth living. Mind you, I don’t go around snatching cigarettes out of people’s mouths. And I’m not sure that I would forcibly try to stop someone from committing suicide solely because it would be immorally self-destructive. The impermissibility of someone else’s conduct doesn’t necessarily give me permission to interfere with it. By the same token, however, I think that encouraging or assisting others in impermissible conduct is itself impermissible. That’s why I think that the tobacco industry is engaged in an immoral enterprise. And it’s why I think the same of Dr. Kevor- kian, who has done more than anyone to help people die by their own convictions. Note that these moral judgments distinguish between self-destruc- tion and mere self-harm. As I have said, I believe that people are some- times entitled to act on mistaken judgments about their own interest; and to this extent, at least, they are entitled to harm themselves. But the behaviors that I have criticized don’t merely damage the agents’ inter- ests; indeed, they may not damage the agents’ interests at all, if the agents are right about the costs and benefits involved. These behaviors 614 Ethics April 1999 This content downloaded from 128.205.114.91 on Mon, 22 Aug 2016 20:58:06 UTC All use subject to http://about.jstor.org/terms are to be criticized, in my view, because they are premised on a disregard for the value of the agents themselves. The same criticism would apply, for example, to agents who put up their own freedom as collateral in order to obtain loans. People have no right to sell themselves into slavery, no matter what their convictions, but the reason is not that they would thereby be harming themselves; the reason is that they would be violating … Suppose, as I think most people would agree, that it would be permissible to grow a single organ in this way in order to save a person’s life. If it would be permissible to grow one organ this way, it should also be permissible to grow two—for example, if the person needed two organ transplants rather than just one. But, if it would be ac- ceptable to grow two organs separately, it should be acceptable to grow three, or four, or five. Imagine that a person has a rare disease that can be cured only by a series of tissue grafts to most parts of his body. To cure him, it would be necessary to use the techniques of stem-cell-based biosynthesis to grow organic replicas of most of his body parts and then graft a small amount of each replica into the corresponding part of his body. It is hard to see how it could be wrong to grow a set of separate organs and body parts in this way. It would be macabre, certainly, but it is hard to see how the organs themselves could have a moral status that would make it wrong to create them for instrumental purposes, or to use or even to destroy them once they were cre- ated. But if there is no objection to creating each organ or body part separately, it ought equally to be acceptable to grow them all together in the form of an anen- cephalic clone. It would, of course, make a difference if they were grown together as an organism with a functional brain, for that would involve the existence of a further, distinct entity with interests and rights. But if the clone is anencephalic, the only dif- ference is that the organs and parts would be physically integrated and mutually sup- porting rather than maintained separately, each on its own scaffolding of combined organic and inorganic support systems. And it is hard to believe that this could make the difference between permissibility and impermissibility. It seems, rather, that the intrinsic moral status of an anencephalic clone—that is, the moral status it has based on its intrinsic rather than relational properties—is no different from that of a collec- tion of separately grown organs. 2. euthanasia and assisted suicide 2.1. From Suicide to Euthanasia “Suicide” and “euthanasia” are concepts with blurred edges. It is often unclear whether a certain act counts as suicide or whether an act is an instance of euthanasia. These conceptual problems merit discussion, but only a rather brief discussion here. In the past, some of these questions were thought to have profound significance. For example, when it was widely accepted that suicides were excluded from heaven, it seemed of the utmost importance to be able to determine whether a particular act was an instance of suicide. Here, by contrast, the main point of the conceptual prelimi- naries is simply to delimit the subject matter of this section of the book. Let us say that an agent commits suicide if he dies as a consequence of acting with the intention of bringing about his own death. This allows that suicide can be ei- ther by act or by omission. It thus treats as an instance of suicide the act of a person who dies as a result of refusing a life-saving medical treatment on the ground that he wished to die rather than to continue to live. Yet the definition’s reliance on the no- tion of intention introduces substantial unclarity. It is clear that a person who acci- dentally or inadvertently causes his own death does not commit suicide; and it is equally clear that a person who deliberately kills himself (for example, by putting a Endings 455 gun to his head and pulling the trigger) does commit suicide. Whether, in the latter case, the agent intends his own death as an end or whether he intends it as a means to an end (for example, the punishment of his wife or, perhaps, the relief of his own suf- fering) is immaterial. I believe, though others have disputed this, that it is also im- material whether the agent acts under duress or coercion.50 There is nothing para- doxical about the notion of a coerced suicide. It is also reasonably clear that, when a person does something that he merely foresees may or will result in his death (such as playing Russian roulette), he does not necessarily commit suicide. But what about cases in which a person intentionally uses himself in a way that he believes will re- sult in his own death? Examples include the soldier in a foxhole who flings himself on a live grenade to shield his comrades, and the man who deliberately attracts the at- tention of a deadly wild animal to himself in order to allow his child to escape. Have such people, when they are killed, committed suicide? Our inclination is to deny that they have. And certainly it is reasonable to see these deaths as foreseen but unintended; for, in each case, if the act had accomplished the person’s aim without resulting in the person’s death (for example, if the grenade had merely maimed the soldier or if the animal had mauled but not killed the parent), none of his intentions or plans would thereby have been thwarted. Yet there is another sense, associated with traditional readings of the Doctrine of Double Effect, in which these people’s deaths are intentional. To see this, we need only to imagine variants of the cases in which the agent sacrifices someone else rather than himself. If, for ex- ample, the soldier were to fling someone else on the grenade, most people would see this as an instance of intentional killing—that is, an instance of killing one person as a means of saving others, hence a paradigm of the sort of act that the Doctrine of Double Effect ought to condemn. Perhaps we should say that, even though the death would not be an intended effect in the narrow sense distinguished in section 10.1 of chapter 4, it nevertheless has, because of its relation to the agent’s intentions, the same significance as an intended effect. If so, the question is then whether, in the orig- inal cases, the presence of this same relation between the agent’s death and his inten- tions makes it appropriate to count these cases as instances of self-sacrificial suicide. I will not pursue these complications here, though I have discussed the analysis of intention elsewhere.51 Because our concern is primarily with euthanasia, we can confine our brief discussion of suicide to cases that are relevantly parallel—that is, cases in which an agent brings about his own death because he believes that his sub- sequent life would not be worth living, and hence that death would be better for him than continued life. In these cases, the death is an intended effect on any account. Next, a few words about the concept of euthanasia. An act of euthanasia, as I will understand the term, is an act of killing or of letting someone die that satisfies two conditions: first, that death benefits, or is good for, the individual who dies and, sec- ond, that the agent must be motivated to do what is good for that individual and must intend to benefit the individual in bringing about his death. Even if an act that brings about a person’s death is intended thereby to benefit the person, it does not count as euthanasia if it is not in fact good for that person. If it would have been better for the person to continue to live, the act may be an instance of intended euthanasia or at- tempted euthanasia, but it is not actually euthanasia. Similarly, if an act of killing or letting die is not intended to benefit the individual who is killed or allowed to die, it 456 the ethics of killing does not become an act of euthanasia if, fortuitously, it turns out to have been better for the individual to die rather than to continue to live. There is an interesting conceptual question that I have never seen discussed in the literature on human euthanasia. This question arises from a problem frequently en- countered in veterinary medicine. Suppose that a man brings his dog to the vet and requests that it be “put to sleep.” When asked why he wants the dog killed, the man replies that he and his family are going on a long trip and cannot afford to have the dog kept in a kennel (or that the dog wets the carpet, that the children have lost inter- est in it, or whatever). Although killing an animal in circumstances such as these is commonly known as “convenience euthanasia,” it may seem that this is just a euphe- mism, for it cannot be good for an animal to be killed when it is perfectly healthy. But there may be more to it than this. The vet may have reason to believe that, if she does not kill the animal painlessly, its owner will take it away and kill it himself, in a man- ner that would not be painless, or that he will turn it loose to starve or be hit by a car. Suppose, in fact, that the man has credibly threatened to do something of this sort. The vet might, of course, offer to take the animal and give it a home herself. But sup- pose that she gets two cases of this sort every week—far more animals than she her- self could care for or even find homes for. In each individual case, then, the situation is that there is an animal whose life could in principle be worth living but no one is willing, nor perhaps obliged, to do what is necessary to make it worth living. The vet therefore has the choice, in practice, between painlessly killing the animal and al- lowing it to live a life that she has good reason to believe will in fact be worth not liv- ing. A parallel case could arise in the case of a human being—for example, if a per- son’s life will be worth not living unless he has a surgical procedure that he cannot afford and that would be so expensive that no one else is willing or obliged to provide it for him. In these circumstances, would it count as euthanasia to kill him and could it be permissible to do so? Again I raise these questions only to put them aside. I will restrict my attention here to cases in which it is not possible to change an individual’s life in a way that would make it worth living. I will briefly note a few common distinctions and then turn to substantive matters. Euthanasia is said to be voluntary when a person freely and autonomously requests or consents to be killed or allowed to die for his own good. It is nonvoluntary when it is not possible for the individual who is killed or allowed to die either to give or to with- hold consent. This category, therefore, encompasses all cases of euthanasia in which the individual killed or allowed to die is a fetus, an infant, an animal, a congenitally severely cognitively impaired human being, or a human being who has ceased to be competent to form autonomous preferences about life and death, and who has not previously expressed his will on the matter. Euthanasia is said to be involuntary when an individual who is competent to give or withhold consent is killed or allowed to die either contrary to his expressed will or when his consent has not been sought. (There may be cases in a gray area between nonvoluntary and involuntary euthanasia in which an individual, though capable of expressing a preference, lacks the compe- tence to have an informed, autonomous preference.) Finally, killing an individual for his own good is commonly referred to as active euthanasia, whereas letting an indi- vidual die when that is in his best interests is referred to as passive euthanasia. Endings 457 It has sometimes been remarked that it is difficult to accept that suicide can be morally permissible without accepting that euthanasia can be as well.52 And indeed there are only a few short steps between the premise that suicide can be permissible and the claim that euthanasia can be. Consider a case in which a person’s life is worth not living: it is and will remain dominated by pain and suffering that cannot be alleviated and that are not counter- balanced by compensating goods. Some people, of course, claim that life is always worth living, or at least that it always can be made to be worth living. But if it is true that pain and suffering are in themselves bad, it seems that a life that contains little or nothing but pain and suffering—one, moreover, that is neither redeemed by its good effects on others nor elevated, ennobled, or enlightened by the experience of suffer- ing—cannot be worth enduring. I will assume that, when a life is bad in this way for the one whose life it is, and when that individual’s death would not be worse for any- one else, it can be prudentially rational for that individual to commit suicide. Most people accept that, in these circumstances, suicide would also not be immoral. Cer- tainly few people now accept that someone who commits suicide in such circum- stances is guilty of murder. Let us assume, conditionally, that, when suicide is rational and not worse for others, it is also morally permissible. Most people also accept that there are circum- stances in which it is permissible to assist someone to commit suicide. Consider, for example, a case in which a person’s suicide would be rational and not worse for others but in which the person cannot easily bring about his own death because he is tethered to a battery of life-support machines from which it would be difficult to ex- tricate himself. Most of us believe that, in these circumstances, it would be permis- sible for the person’s physician to accede to his request to collaborate with him in withdrawing the life-support systems—for example, by assisting the person to re- move the various pieces of apparatus from his body. Indeed, most of us believe that, provided that the person is competent, the physician ought to enable him to free him- self from the machines. Given that the withdrawal of the life-support systems will lead immediately to the person’s death, we should regard the person’s removal of them as an act of suicide, albeit an instance of “passive suicide,” since he does not create the cause of his death but instead allows himself to die by removing the pro- tections that have thus far been saving him from a preexisting threat. In assisting him to remove these protections, the physician assists him to commit suicide. I have described a case in which a person chooses to die “passively” by ceasing to resist a threat of death that is not of his own making. In most cases, people com- mit suicide actively, by creating the threat that results in their death. Many people re- gard it as impermissible to assist someone in actively committing suicide, and it is at present illegal in most areas of the United State for physicians to assist their patients in actively killing themselves—for example, by prescribing a lethal dose of some medicine. Yet it is hard to see how it could be permissible to provide assistance to a passive suicide but not to an active suicide. How could the permissibility of assis- tance by a third party depend on whether the person bent on suicide chooses an ac- tive or a passive means, particularly when either would be equally permissible? It is tempting to appeal here to the general claim that, if it is permissible for a per- son to do something, it must also be permissible for others to assist him. But that 458 the ethics of killing claim seems false. There are, for example, rare circumstances in which one wholly innocent person will be killed by another wholly innocent person unless the one kills the other first. In these circumstances, it may be permissible for each to try to kill the other but not permissible for a third party to assist either. For while it may be per- missible for each agent to give priority to himself, a neutral third party may be re- quired to treat both principals equally and impartially and may therefore be forbid- den to provide assistance to either at the expense of the other.53 But it seems that this restriction on the permissibility of assistance by third parties applies only in cases in which what an agent is permitted to do may prevent others from doing what they are permitted to do or otherwise have adverse effects on others. In the case of a rational suicide that would not be worse for others, these complications do not arise; there- fore there is no reason to suppose that a third party may not assist the agent in doing what it is permissible for that agent to do. There are, moreover, positive reasons why, in the case of a rational suicide, as- sistance from others is desirable. People who set out to kill themselves sometimes fail, leaving themselves not only alive but disabled, disfigured, humiliated, and in pain. As Arthur Koestler, “speaking in the name of many . . . who tried and failed,” once observed, “there is only one prospect worse than being chained to an intolerable existence: the nightmare of a botched attempt to end it.”54 And even when people suc- ceed in committing suicide, they are often forced to quit life alone, in terror, without the support or validation of others, and with greater pain and mess than is necessary. If it is prudentially rational and morally permissible for a person to seek death, how much better it would be if he could be assured assistance from others that would en- able him to die with as much comfort, reassurance, and certainty as possible. Thus far we have passed by short steps from the permissibility of rational suicide to the permissibility of assisted passive suicide and assisted active suicide. But we have also, perhaps without noticing it, taken another step as well: to passive euthana- sia. In the case I cited of assisted passive suicide, the physician assists the patient to disconnect himself from the life-support systems. But by refusing to collaborate, or by actively preventing the patient from disconnecting himself, the physician could have kept the patient alive. Therefore this is a case in which the physician allows the patient to die. If the physician is motivated to do this at least in part by the true belief that death would be in the best interest of the patient, her action constitutes an in- stance of passive euthanasia. It seems, in fact, that this is a case in which the cate- gories of assisted suicide and euthanasia overlap: the patient commits suicide, with the physician’s assistance, by refusing to continue to be saved, or kept alive; yet the physician also allows the patient to die, and does so with the intention of thereby ben- efiting him. It would, perhaps, be a more obvious case of passive euthanasia if the physician alone turned off or disconnected all the life-support systems. Assuming that the sys- tems she withdrew were all ones that she had herself been providing, this would be an instance of allowing the patient to die and not a case of killing—in short, a case of passive euthanasia, despite the fact that allowing the patient to die required action rather than inaction. Still, in either case—whether the physician assists in the with- drawal of the life-support systems or removes them entirely by herself—most of us acknowledge the permissibility of her action. We accept, in short, the permissibility Endings 459 of at least some instances of voluntary passive euthanasia. For it is widely accepted that a physician not only may but must comply with a patient’s competent request for the termination of life-supporting medical aid. And it would seem absurd to suppose that, while the physician could permissibly remove the patient from life-support systems, she could not permissibly do so with the intention of benefiting the patient by enabling him to die. Passive euthanasia is, however, as far as we as a society have so far been willing to go. Many people, at least when they consider the matter in the abstract, think that there is a sharp moral line—one that must not be crossed—between allowing some- one to die when it is in his interest to die and actually killing him. But when one con- siders the matter closely, it seems that the step from passive to active euthanasia is again a very short one. Consider, for example, the activities of the notorious Dr. Jack Kevorkian. (Let us put aside whatever reservations we may have about his character and methods: his publicity seeking, megalomania, insufficient knowledge of his “clients,” and so on.) His earlier cases were instances of assisted suicide: he hooked people up to a device containing a lethal chemical, but the people themselves actu- ally pressed the button that released the chemical into their bloodstream. By contrast, in a more recent case, the person—a man named Youk—suffered from amyotrophic lateral sclerosis and was so disabled that it was difficult for him to push the button. He therefore asked Kevorkian to push it for him, which Kevorkian did, with a video camera rolling all the while. Most of us, on reflection, find it difficult to believe that it could make a momentous moral difference whether Youk pushed the button him- self or whether Kevorkian pushed it for him. Yet that is all that the difference between assisted suicide and killing amounts to. In addition to the fact that it seems insignificant who pushes the button, provided that the person whose death it causes autonomously wants it to be pushed, there is an- other feature this case that supports the inference from the permissibility of passive euthanasia to the permissibility of active euthanasia. This is Youk’s apparent inabil- ity to press the button himself. Most people who desperately want to die are capable of killing themselves and thus seek the assistance of others only in order to ensure that their own action is painless, minimally shocking to others, and successful. If we accept the permissibility of rational suicide (subject, of course, to certain con- straints), and in particular if we accept the permissibility of assisting in the commis- sion of rational suicide, we are acknowledging that people have a right to die when life has become an intolerable burden and when continued life is not demanded by consideration of others. If, however, we reject the permissibility of active euthanasia, we are effectively denying that right to those who are so disabled that they cannot take their own lives, even with assistance from others. In order for those people to es- cape from an intolerable existence, it is necessary for someone else to kill them. If we forbid others to kill them, when there are others who are willing to do so, we are ex- acerbating the already quite terrible hardships these people have had to bear. Thus some advocates of the rights of the disabled have claimed, with considerable plausi- bility, that a policy that permits suicide but forbids active euthanasia unfairly dis- criminates against the disabled. Despite these considerations, many people are unable to evade the nagging sense that killing another person is fundamentally different from allowing him to die or 460 the ethics of killing even assisting him to kill himself. Yet how can they explain why, intuitively, it seems to make no difference whether Youk pressed the button himself or whether Kevorkian pressed it at Youk’s request? Some philosophers have contended that cases of this sort—in which the distinction between killing and letting die seems to have no moral significance—show that the distinction is, in these cases and all others, devoid of sig- nificance. They argue that, because we are wrong to suppose that the distinction has moral significance, we must acknowledge that, in the absence of contingent differ- ences, active euthanasia must be permissible when passive euthanasia would be—par- ticularly in cases in which merely allowing a person to die would prolong his agony.55 I believe that there is a different and more plausible explanation of why it is no worse for Kevorkian to press the button, thereby killing Youk, than it is for Youk to press it himself. This explanation is compatible with, and indeed presupposes, the be- lief that the distinction between killing and letting die is, in general, morally signifi- cant. It assumes that, if the distinction has moral significance, that must be because it is an instance of the more general distinction between doing and allowing. Most people believe that a person’s actively bringing about an outcome that would not have occurred without his intervention has a different moral significance from a person’s allowing that outcome to occur. Perhaps the active causing of the outcome ties the agent more closely to it, making him more responsible for it than he would have been if it had occurred even in his absence. I will not attempt to defend any particular ex- planation of the moral significance of the distinction between doing and allowing. If, however, this broad distinction does have a general significance, it offers an explana- tion of why killing is in general more seriously wrong than letting someone die. If, in general, the mode of agency involved in actively intervening to bring about an out- come is morally more significant than that involved in allowing an outcome to occur, it seems that doing harm must in general be more seriously morally objectionable than allowing harm to occur. Because death is normally harmful to those who die, it follows that killing must in general be more seriously objectionable than letting die. Notice, however, that the significance of the distinction between doing and allow- ing should be reversed in cases in which the outcome is good rather than bad. If doing harm is worse than allowing harm to occur, actively benefiting someone should, in general, be better than merely allowing someone to be benefited, even when all other things (such as motive, intention, cost to the agent, and so on) are equal. If that is right, it explains why it was not worse for Kevorkian to press the button, thereby killing Youk, than it would have been for him to have allowed Youk to die by allowing him to press the button instead. For Youk’s death was unusual in not being harmful to him. It was instead beneficial; hence, if benefiting someone is better than merely allowing him to be benefited (for example, allowing him to benefit himself), Kevorkian’s ac- tively bringing about that death was, if anything, better or more praiseworthy than merely allowing or enabling Youk to bring it about would have been. Because, in cases of euthanasia, death is beneficial rather than harmful, active eu- thanasia should in general be better or more imperative than passive euthanasia.56 To suppose otherwise is to divorce the distinction between killing and letting die from its source in the distinction between doing and allowing, and to treat the general pro- scription of killing as a taboo rather than as a rational moral requirement to which there are intelligible exceptions. It is, of course, desirable that each of us should be Endings 461 profoundly averse to killing other human beings and that this aversion should be sed- ulously inculcated as a fundamental element of each person’s moral education. But the aversion should retain its grounding in the reasons we have for refraining from killing; it should not degenerate into an indiscriminate squeamishness. If, for example, the reason not to kill persons derives from a requirement of respect for persons, we should seek to prevent our aversion to wrongful killing from spilling over into cases in which killing is compatible with, and perhaps even required by, respect for a person. I will consider presently whether voluntary active euthanasia is a case of this sort. The argument from suicide to euthanasia starts from cases in which suicide is both prudentially and morally justified. Often, of course, suicide is either pruden- tially or morally unjustified, or both. A great many people commit suicide in the mis- taken belief that their lives are not or will not be worth living. This is an easy mistake to make: one’s predictions about the character and content of one’s future life may be faulty; and, even if they are accurate, one may inadequately imagine what such a life would be like or fail to appreciate one’s ability to adapt oneself to it. Thus even if one accepts that suicide and euthanasia can in principle be justified, one should recognize that there will be cases in which it will be justified to restrain a person from commit- ting suicide, or to deny a person’s request for assistance in committing suicide or for “euthanasia,” on the ground that the person is mistaken in believing that his life is worth not living. The difficulty of discriminating between these cases and those in which the person’s life is genuinely not worth living is, of course, one of the major problems with accepting the legitimacy of assisted suicide and euthanasia. Let us, however, confine our attention to cases in which it is true, and all those in- volved can agree that it is true, that a person’s life is worth not living. Even in these cases, suicide or euthanasia may be unjustified because of its effects on others. There are individual cases in which a person’s death would be so harmful to others that the person ought morally to endure a miserable existence for the sake of those others. These cases are, however, comparatively rare. For those who care enough about a person to be devastated by his death are normally motivated by love to give that per- son’s interests priority over their own. Still, there remain some cases in which a pru- dentially rational suicide is morally unjustified because of its effects on others—for example, a suicide by a single parent that … Flexibility ..._ Flexibility allows the safe use of a wide range of movements. Flexibility is an essential part oftraining because it allows us to use a wide range ofmovements safely. In some sports such as gymnastics, flexibility is high on the list oftraining priorities. Coaches ofsuch sports have their own methods of assessing improvements in flexibility. Comprehensive and reproducible assessment is difficult to achieve, however, because ofthe complex nature ofmovement. Nevertheless, carefully controlled measurements, albeit in limited ranges ofmovements, can be used to assess flexibility with a simple set ofgoniometers. It is particularly important that the measurements are standardised and that in longitudinal studies the same person performs all the measurements. The results can contribute useful information in assessing overall fitness when this strict code of practice is followed. Conclusion Clyde Williams is professor of sports science at the University ofLoughborough. The ABC of Sports Medicine has been edited by Greg McLatchie, visitingprofessor ofsports medicine and surgical sciences at the University ofSunderland, consultant surgeon at Hartlepool General Hospital, and director ofthe National Sports Medicine Institute, London. Fitness is a complex physiological characteristic that is difficult to describe comprehensively. Nevertheless, we can assess the central elements of fitness in reliable and reproducible ways. Through assessing athletes fitness we can extend health care by advising them on their ability to cope with the exercise demands of their chosen sport. The photographs of the javelin thrower (Tessa Sanderson) and of the woman gymnast- (Jackie Brady) were taken by Supersport Photographs. Imperial College of Science, Technology and Medicine, London SW7 INA Raanan Gillon, visiting professor ofmedical ethics BMY 1994;309:184-8 Medical ethics: four principles plus attention to scope Raanan Gillon The four principles plus scope approach provides a simple, accessible, and culturally neutral approach to thinking about ethical issues in health care. The approach, developed in the United States, is based on four common, basic prima facie moral commit- ments-respect for autonomy, beneficence, non- maleficence, and justice-plus concern for their scope of application. It offers a common, basic moral analytical framework and a common, basic moral language. Although they do not provide ordered rules, these principles can help doctors and other health care workers to make decisions when reflecting on moral issues that arise at work. Nine years ago the BMJ allowed me to introduce to its readers an approach to medical ethics developed by the Americans Beauchamp and Childress, which is based on four prima facie moral principles and attention to these principles scope of application. Since then I have often been asked for a summary of this approach by doctors and other health care workers who find it helpful for organising their thoughts about medical ethics. This paper, based on the preface of a large multiauthor textbook on medical ethics,3 offers a brief account of this four principles plus scope approach. The four principles plus scope approach claims that whatever our personal philosophy, politics, religion, moral theory, or life stance, we will find no difficulty in committing ourselves to four prima facie moral principles plus a reflective concern about their scope of application. Moreover, these four principles, plus attention to their scope of application, encompass most of the moral issues that arise in health care. The four prima facie principles are respect for autonomy, beneficence, non-maleficence, and justice. Prima facie, a term introduced by the English philosopher W D Ross, means that the principle is binding unless it conflicts with another moral principle -if it does we have to choose between them. The four principles approach does not provide a method for choosing, which is a source of dissatisfaction to people who suppose that ethics merely comprises a set of ordered rules and that once the relevant information is fed into an algorithm or computer out will pop the answer. What the principles plus scope approach can provide, however, is a common set of moral commitments, a common moral language, and a common set of moral issues. We should consider these in each case before coming to our own answer using our preferred moral theory or other approach to choose between these principles when they conflict. Respect for autonomy Autonomy-literally, self rule, but probably better described as deliberated self rule-is a special attribute 184 BMJ VOLUME 309 16 JULY 1994 of all moral agents. If we have autonomy we can make our own decisions on the basis of deliberation; some- times we can intend to do things as a result of those decisions; and sometimes we can do those things to implement the decisions (what I previously described as autonomy of thought, of will or intention, and of action). Respect for autonomy is the moral obligation to respect the autonomy of others in so far as such respect is compatible with equal respect for the autonomy of all potentially affected. Respect for autonomy is also sometimes described, in Kantian terms, as treating others as ends in themselves and never merely as means-one of Kants formulations of his categorical imperative. In health care respecting peoples autonomy has many prima facie implications. It requires us to consult people and obtain their agreement before we do things to them-hence the obligation to obtain informed consent from patients before we do things to try to help them. Medical confidentiality is another implication of respecting peoples autonomy. We do not have any general obligation to keep other peoples secrets, but health care workers explicitly or implicitly promise their patients and clients that they will keep confidential the information confided to them. Keeping promises is a way of respecting peoples autonomy; an aspect of running our own life depends on being able to rely on the promises made to us by others. Without such promises of confidentiality patients are also far less likely to divulge the often highly private and sensitive information that is needed for their optimal care; thus maintaining confidentiality not only respects patients autonomy but also increases the likelihood of our being able to help them. Respect for autonomy also requires us not to deceive each other (except in circumstances in which deceit is agreed to be permissible, such as when playing poker) as the absence of deceit is part of the implicit agreement among moral agents when they communicate with each other. They organise their lives on the assumption that people will not deceive them; their autonomy is infringed if they are deceived. Respect for patients autonomy prima facie requires us, therefore, not to deceive patients, for example, about their diagnosed illness unless they clearly wish to be deceived. Respect for autonomy even requires us to be on time for appointments as an agreed appointment is a kind of mutual promise and if we do not keep an appointment we break the promise. To exercise respect for autonomy health care workers must be able to communicate well with their patients and clients. Good communication requires, most importantly, listening (and not just with the ears) as well as telling (and not just with the lips or a wordprocessor) and is usually necessary for giving patients adequate information about any proposed intervention and for finding out whether patients want that intervention. Good communication is also usually necessary for finding out when patients do not want a lot of information; some patients do not want to be told about a bad prognosis or to participate in deciding which of several treatments to have, preferring to leave this decision to their doctors. Respecting such attitudes shows just as much respect for a patients autonomy as does giving patients information that they do want. In my experience, however, most patients want more not less information and want to participate in deciding their medical care. Beneficence and non-maleficence Whenever we try to help others we inevitably risk harming them; health care workers, who are committed to helping others, must therefore consider the prin- ciples of beneficence and non-maleficence together and aim at producing net benefit over harm. None the less, we must keep the two principles separate for those circumstances in which we have or recognise no obligation of beneficence to others (as we still have an obligation not to harm them). Thus the traditional Hippocratic moral obligation of medicine is to provide net medical benefit to patients with minimal harm- that is, beneficence with non-maleficence. To achieve these moral objectives health care workers are com- mitted to a wide range ofprima facie obligations. We need to ensure that we can provide the benefits we profess (thus professional) to be able to provide. Hence we need rigorous and effective education and training both before and during our professional lives. We also need to make sure that we are offering each patient net benefit. Interestingly, to do this we must respect the patients autonomy for what constitutes benefit for one patient may be harm for another. For example, a mastectomy may constitute a prospective net benefit for one woman with breast cancer, while for another the destruction of an aspect of her feminine identity may be so harmful that it cannot be outweighed even by the prospect of an extended life expectancy. The obligation to provide net benefit to patients also requires us to be clear about risk and probability when we make our assessments of harm and benefit. Clearly, a low probability of great harm such as death or severe disability is of less moral importance in the context of non-maleficence than is a high probability of such harm, and a high probability of great benefit such as cure of a life threatening disease is of more moral importance in the context of beneficence than is a low probability of such benefit. We therefore need empirical information about the probabilities of the various harms and benefits that may result from proposed health care interventions. This information has to come from effective medical research, which is also therefore a prima facie moral obligation. The obligation to produce net benefit, however, also requires us to define whose benefit and whose harms are likely to result from a proposed intervention. This problem of moral scope is particularly important in medical research and population medicine. One moral concept that in recent years has become popular in health care is that of empowerment-that is, doing things to help patients and clients to be more in control of their health and health care. Sometimes empowerment is even proposed as a new moral obligation. On reflection I think that empowerment is, however, essentially an action that combines the two moral obligations of beneficence and respect for autonomy to help patients in ways that not only respect but also enhance their autonomy. Justice The fourth prima facie moral principle is justice. Justice is often regarded as being synonymous with fairness and can be summarised as the moral obligation to act on the basis of fair adjudication between competing claims. In health care ethics I have found it useful to subdivide obligations of justice into three categories: fair distribution of scarce resources (distributive justice), respect for peoples rights (rights based justice) and respect for morally acceptable laws (legal justice). Equality is at the heart of justice, but, as Aristotle argued so long ago, justice is more than mere equality -people can be treated unjustly even if they are treated equally.45 He argued that it was important to treat equals equally (what health economists are increasingly calling horizontal equity) and to treat unequals unequally in proportion to the morally relevant inequalities (vertical equity). People have argued ever since about the morally relevant criteria for BMJ VOLUME 309 16 JULY 1994 185 regarding and treating people as equals and those for regarding and treating them as unequals. The debate flourishes in moral, religious, philosophical, and political contexts, and we are no closer to agreement than we were in Aristotles time. Pending such agreement health care workers need to tread warily as we have no special justification for imposing our own personal or professional views about justice on others. We certainly need to recognise and acknowledge the competing moral concerns. For example, in the context of the allocation of resources conflicts exist between several common moral concerns: to provide sufficient health care to meet the needs of all who need it; when this is impossible, to distribute health care resources in proportion to the extent of peoples needs for health care; to allow health care workers to give priority to the needs of their patients; to provide equal access to health care; to allow people as much choice as possible in selecting their health care; to maximise the benefit produced by the available resources; to respect the autonomy of the people who provide those resources and thus to limit the cost to taxpayers and subscribers to health insurance schemes. All these criteria for justly allocating health care resources can be morally justified but not all can be fully met simultaneously. Similar moral conflicts arise in the context of rights based justice and legal justice. PERSONAL DECISION MAKING The best moral strategy for justice that I have found for myself as a health care worker is first to distinguish whether it is I or an organisation, profession, or society itself that has to make a decision. For example, how should I respond to a particular patient who wants an abortion? is distinct from, what is this hospitals organisational view on abortion? and what is the medical professions collective view on abortion? and what is societys view as expressed in law and practice? Firstly, for decisions that I must take myself I must try to exclude decisions that have no moral basis or justification. Neither pursuit of my own self interest -for example, accepting bribes from patients, hospitals, or drug manufacturers-nor action that discriminates against patients on the basis of personal preference or prejudice can provide a just or morally acceptable basis for allocating scarce health care resources or for any other category ofjustice. Moreover, it is not my role as a doctor to punish patients; withholding antibiotics from smokers who do not give up smoking or refusing to refer heavy drinkers with liver damage induced by alcohol for specialist assess- ment on the grounds that they are at fault is not a just or morally acceptable basis for rationing my medical resources. Secondly, I should not waste the resources at my disposal; so if a cheaper drug is likely to produce as much benefit as a more expensive one I should prescribe the cheaper one. Cost and its team mate opportunity cost are moral issues and central to distributive justice. If I believe, however, that an expensive drug is clearly and significantly better for my patient than a cheaper alternative and I am allowed to prescribe it then I believe that I should do so. Thus, like many British general practitioners, I try oxytetracycline first when treating acne, but if it does not work well I prescribe the more expensive minocycline; for depression I usually start with tri- cyclic antidepressants, but if they do not work well or the side effects are unacceptable I prescribe the new and expensive 5-hydroxytryptamine uptake inhibitors. Thirdly, I should respect patients rights. For example, my disapproval of a patients lifestyle would not be a morally acceptable justification for refusing to provide a certificate of sickness ifhe or she cannot work because of sickness. I have no special privilege as a health care worker, however, to create societal rights for my patients. For example, while I might think that all my unemployed patients should receive sickness benefit, in Britain they have a right to receive it only if they cannot work because of sickness; I have a right, therefore, to provide a certificate of sickness only if this is the case. Fourthly, I ought to obey morally acceptable laws. Thus, even though I may disapprove of breaking a patients confidence, if he or she has one of several infectious diseases I am legally obliged to notify the relevant authorities. If I believe that the law is morally unjustified I am morally entitled to break the law; but this gives me no legal entitlement to break the law, and I should be prepared to face the legal consequences of disobeying it. I should also decide exactly what I mean by a morally unjustified law. I suggest, though here do not argue, that it is the processes through which laws are enacted that confer moral legitimacy not the content of the laws. Thus if a law is enacted through a democratic political system-and hence one that fundamentally respects autonomy-which represents conflicting views within its population and makes laws on the basis of certain common moral values that reflect the four principles then that law is morally acceptable, and prima facie we are morally required to obey it. ORGANISATIONAL, PROFESSIONAL, AND SOCIETAL DECISIONS My role in taking decisions about justice that are organisational, professional, or societal should only be as a member of the relevant organisation, profession, or society. It is therefore morally consistent to pursue at different levels objectives that are mutually in- consistent. The medical directorate at the hospital where I work may have decided to prohibit the prescription of a particularly expensive drug. As a member of that directorate I may have argued in favour of prescribing the drug in special cases, but my arguments were rejected. It is morally proper for me as a clinician to accept the directorates decision and act accordingly even when faced with an exceptional case in which I believe the expensive drug would be preferable. It is also morally legitimate for me to point to such cases (shroud waving) in my political role as a member of a democratic society, arguing, for example, for more resources for health care than, say, for defence. As members of society we are still feeling our way even at the level of defining what the competing moral concerns of justice are. We must be particularly wary of apparently simple solutions to what have been perceived as highly complex problems for at least 2500 years. For example, populist solutions in distributive justice such as have occurred in Oregon in the United States6 and technical and simplistic economic solutions such as the system of costed quality adjusted life years (QALYs) are tempting in their definitiveness and simplicity; they fail, however, to give value to the wide range of other potentially relevant moral concerns. Until there is far greater social agreement and understanding of these exceed- ingly complex issues I believe it is morally safer to seek gradual improvement in our current methods of trying to reconcile the competing moral concerns-to seek ways of muddling through elegantly as Hunter advocates&-than to be seduced by systems that seek to convert these essentially moral choices into apparently scientific, numerical methods and formulas. As Calabresi and Bobbitt suggested in the 1970s, rationing scarce resources that prolong life and enhance health often entails tragic choices-choices between BMJ VOLUME 309 16 JULY 1994186 people and between values. Societies seek strategies to minimise the destructive effect of such choices, including tendencies to change their strategies over time.9 Calabresi suggests that we are like a juggler trying to keep too many balls in the air; like the juggler we must do our best to improve our juggling skills to keep more balls in the air for more of the time and to avoid letting any ball stay on the ground for too long. We must accept, however, that in the context of competing and mutually incompatible claims there will always be some balls on the ground. Moreover, we should not be surprised that there will always be some people dissatisfied after justice has been done because by definition not everyones claims can be met. Scope We may agree about our substantive moral commit- ments and our prima facie moral obligations of respect for autonomy, beneficence, non-maleficence, and justice, yet we may still disagree about their scope of application-that is, we may disagree radically about to what or to whom we owe these moral obligations. Interesting and important theoretical issues surround the scope of each of the four principles. We clearly do not owe a duty of beneficence to everyone and everything; so whom or what do we have a moral duty to help and how much should we help them? While we clearly have a prima facie obligation to avoid harming everyone, who and what count as everyone? Similarly, even if we agree that the scope of the principle of respect for autonomy is universal, encompassing all autonomous agents, who or what counts as an autonomous agent? Who or what falls within the scope of our obligation to distribute scarce resources fairly according to the principle of justice? Is it everyone in the world? Future people? Just people in our own countries? And who or what has rights? Do plants have rights? Does the environment have rights? Does a work of art have rights? Do animals have rights and if so, which animals? Conversely, against whom may holders of rights claim the correlative moral obligation? Similar questions concern the scope of legal justice. SCOPE FOR HEALTH CARE WORKERS Fortunately for health care workers some of these issues of scope have been clarified for them by their special relationship with their patients or clients. In particular, the controversial issue of who falls within the scope of beneficence is answered unambiguously for at least one category of people: all health care workers have a moral obligation to help their patients and clients. Patients or clients fall within the scope of the health care workers duty of beneficence. This fact is established by the personal and professional commitments of the health care professionals and their organisations-they all profess a commitment to help their patients and clients, and to do so with minimal harm. This commitment is underwritten by the societies in which they practise, both informally and through legal rules and regulations that define the health care professionals duties of care. Two issues of scope are of particular practical importance for health care workers. The first is the question ofwho falls within the scope of the prima facie principle of respect for autonomy. The second is the question of what is the scope of the widely acknowledged right to life; who and what has a right to life? Obviously the scope of the principle of respect for autonomy must include autonomous agents-we cannot respect the autonomy of a boot or anything else that is not autonomous. But who or what counts as an autonomous agent? When we disagree about whether or not to respect the decision of a girl of 14 to take the oral contraceptive pill we are in effect disagreeing about the scope of application of the principle of respect for autonomy. Similar questions about the scope of respect for autonomy arise in other paediatric contexts, in the care of severely mentally ill or mentally impaired people, and in the care of elderly people who are severely mentally impaired. Some patients clearly do not fall within the scope of respect for autonomy; newborn babies, for example, are not autonomous agents as autonomy requires the capacity to deliberate. But 7 year olds usually can deliberate to a degree. How much capacity for logical thought and deliberation and what other attributes are required for somebody to be an adequately autonomous agent? Possible other, necessary attributes include an adequately extensive and accurate knowledge base, including that born of experience and of accurte perception, on which to deliberate; an ability to conceive of and reflect on ourselves over time, both past and future; an ability to reason hypothetically-what if reasoning; an ability to defer gratification for ourselves as an aspect of self rule; and sufficient will power for self rule. However these philosophical questions are an- swered, health care workers increasingly acknowledge that the autonomy of even young children and severely mentally impaired people should prima facie be respected unless there are good moral reasons not to do so. Moreover, those reasons will depend highly on the context; a young child or a severely mentally impaired person may not be autonomous enough to have his or her decision to reject an operation respected but be autonomous enough to decide what food to eat or clothes to wear. When patients who are not adequately autonomous for all their decisions to be respected make decisions that seem to be against their ifiterests then important issues arise about who should be regarded as appropriate to make decisions on their behalf and about the criteria that they should use to do so. The second important issue of scope for health care workers concerns the right to life. Who or what has this right to life? To answer the question we have to determine what is meant by the right to life. Specifically, is it simply the right not to be unjustly killed or does it also include a right to be kept alive? The scope of the first right will clearly be greater than the scope of the latter: we have prima facie moral obligations not to kill all people but we have obligations to keep alive only some people. Even with the first definition of the right to life (a right not to be unjustly killed) a question of scope arises; although all people clearly fall within its scope, do (non-human) animals? And what do we mean by people? In response to this last question much debate, often extremely acrimonious, occurs in health care ethics over the right to life of human embryos, fetuses, newborn babies, and patients who are permanently unconscious or even brain dead. It is salutary to reflect that these contentious issues are not about the content of our moral obligations but about to whom and what we owe them-that is, they are questions about the scope of our agreed moral obligations. Our answers are reasoned and carefully argued but deeply conflicting, either religiously or philosophically. Such disagreement about scope does not justify accusing those who disagree with us of bad faith or incompatible moral standards; in principle it is open to resolution within our shared moral commitment. Conclusion The four principles plus scope approach is clearly not without its critics. And the approach does not BMJ VOLUME 309 16 JULY 1994 Pursuit ofjustice-keeping all the balls in the air purport to offer a method of dealing with conflicts between the principles. But I have not found anyone who seriously argues that he or she cannot accept any of these prima facie principles or found plausible examples of concerns about health care ethics that require additional moral principles. The four principles plus scope approach enables health care workers from totally disparate moral cultures to share a fairly basic, common moral commit- ment, common moral language, and common analytical framework for reflecting on problems in health care ethics. Such an approach, which is neutral between competing religious, political, cultural, and philo- sophical theories, can be shared by everyone regardless of their background. It is surely too important a moral prize to be rejected carelessly or ignorantly; for the sake of mere opposition; or for the fun of being a philosophical Socratic gadfly. 1 Gillon R. Philosophical medical ethics. Chichester: Wiley, 1986. (From a 26 part series in BMJ from 1985;290: 1117-9 to 1986;292:543-5.) 2 Beauchamp TL, Childress JF. Principles of biomedical ethics. 3rd ed. New York, Oxford: Oxford University Press, 1989. 3 Gillon R, Lloyd A, eds. Principles ofhealth care ethics. Chichester: Wiley, 1994. 4 Aristotle. Nichomachean ethics. Book 5. McKeon R, ed. The basic works of Aristotle. New York: Random House, 1941. 5 Aristotle. Politics. Book 3, chapter 9. McKeon R, ed. The basic works of Aristotle. New York: Random House, 1941. 6 Klein R. On the Oregon trail: rationing health care-more politics than science. BMJ 1991;302:1-2. 7 Williams A. Economics, society and health care ethics. In: Gillon R, Lloyd A, eds. Principles ofhealth care ethics. Chichester: Wiley, 1994:829-42. 8 Hunter DJ. Rationing dilemmas in health care. Birmingham: National Association ofHealth Authorities and Trusts, 1993. (NAHAT research paper No 8.) 9 Calabresi G, Bobbitt P. Tragic choices. New York: Norton, 1978. (Accepted 16March 1994) This is the seventh in a series of occasional notes on medical statistics. Medical Statistics Laboratory, Imperial Cancer Research Fund, London WC2A 3PX Douglas G Altman, head Department ofPublic Health Sciences, St Georges Hospital Medical School, London SW17 IRE J Martin Bland, reader in medical statistics BMJ 1994309:188 Statistics Notes Diagnostic tests 3: receiver operating characteristic plots Douglas G Altman, J Martin Bland We have previously considered diagnosis based on tests that give a … $�HIHQVH�RI�$ERUWLRQ $XWKRU�V���-XGLWK�-DUYLV�7KRPVRQ 6RXUFH��3KLORVRSK\� �3XEOLF�$IIDLUV��9RO�����1R�����$XWXPQ���������SS������� 3XEOLVKHG�E\��:LOH\ 6WDEOH�85/��http://www.jstor.org/stable/2265091 . $FFHVVHG������������������ Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at . http://www.jstor.org/page/info/about/policies/terms.jsp . JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact [email protected] . Wiley is collaborating with JSTOR to digitize, preserve and extend access to Philosophy &Public Affairs. http://www.jstor.org This content downloaded from 128.205.114.91 on Thu, 25 Sep 2014 13:20:33 PM All use subject to JSTOR Terms and Conditions http://www.jstor.org/action/showPublisher?publisherCode=black http://www.jstor.org/stable/2265091?origin=JSTOR-pdf http://www.jstor.org/page/info/about/policies/terms.jsp http://www.jstor.org/page/info/about/policies/terms.jsp JUDITH JARVIS THOMSON A Defense of Abortion Most opposition to abortion relies on the premise that the fetus is a human being, a person, from the moment of conception. The premise is argued for, but, as I think, not well. Take, for example, the most common argument. We are asked to notice that the development of a human being from conception through birth into childhood is con- tinuous; then it is said that to draw a line, to choose a point in this development and say before this point the thing is not a person, after this point it is a person is to make an arbitrary choice, a choice for which in the nature of things no good reason can be given. It is con- cluded that the fetus is, or anyway that we had better say it is, a per- son from the moment of conception. But this conclusion does not fol- low. Similar things might be said about the development of an acorn into an oak tree, and it does not follow that acorns are oak trees, or that we had better say they are. Arguments of this form are sometimes called slippery slope arguments-the phrase is perhaps self-explana- tory-and it is dismaying that opponents of abortion rely on them so heavily and uncritically. I am inclined to agree, however, that the prospects for drawing a line in the development of the fetus look dim. I am inclined to think also that we shall probably have to agree that the fetus has already become a human person well before birth. Indeed, it comes as a sur- prise when one first learns how early in its life it begins to acquire human characteristics. By the tenth week, for example, it already has i. I am very much indebted to James Thomson for discussion, criticism, and many helpful suggestions. This content downloaded from 128.205.114.91 on Thu, 25 Sep 2014 13:20:33 PM All use subject to JSTOR Terms and Conditions http://www.jstor.org/page/info/about/policies/terms.jsp 48 Philosophy & Public Affairs a face, arms and legs, fingers and toes; it has internal organs, and brain activity is detectable.2 On the other hand, I think that the prem- ise is false, that the fetus is not a person from the moment of con- ception. A newly fertilized ovum, a newly implanted clump of cells, is no more a person than an acorn is an oak tree. But I shall not discuss any of this. For it seems to me to be of great interest to ask what happens if, for the sake of argument, we allow the premise. How, pre- cisely, are we supposed to get from there to the conclusion that abor- tion is morally impermissible? Opponents of abortion commonly spend most of their time establishing that the fetus is a person, and hardly any time explaining the step from there to the impermissibility of abortion. Perhaps they think the step too simple and obvious to require much comment. Or perhaps instead they are simply being eco- nomical in argument. Many of those who defend abortion rely on the premise that the fetus is not a person, but only a bit of tissue that will become a person at birth; and why pay out more arguments than you have to? Whatever the explanation, I suggest that the step they take is neither easy nor obvious, that it calls for closer examination than it is commonly given, and that when we do give it this closer examination we shall feel inclined to reject it. I propose, then, that we grant that the fetus is a person. from the moment of conception. How does the argument go from here? Some- thing like this, I take it. Every person has a right to life. So the fetus has a right to life. No doubt the mother has a right to decide what shall happen in and to her body; everyone would grant that. But surely a persons right to life is stronger and more stringent than the mothers right to decide what happens in and to her body, and so outweighs it. So the fetus may not be killed; an abortion may not be performed. It sounds plausible. But now let me ask you to imagine this. You wake up in the morning and find yourself back to back in bed with an unconscious violinist. A famous unconscious violinist. He has been found to have a fatal kidney ailment, and the Society of Music Lovers 2. Daniel Callahan, Abortion: Law, Choice and Morality (New York, 1970), p. 373. This book gives a fascinating survey of the available information on abortion. The Jewish tradition is surveyed in David M. Feldman, Birth Control in Jewish Law (New York, i968), Part 5, the Catholic tradition in John T. Noonan, Jr., An Almost Absolute Value in History, in The Morality of Abortion, ed. John T. Noonan, Jr. (Cambridge, Mass., 1970). This content downloaded from 128.205.114.91 on Thu, 25 Sep 2014 13:20:33 PM All use subject to JSTOR Terms and Conditions http://www.jstor.org/page/info/about/policies/terms.jsp 49 A Defense of Abortion has canvassed all the available medical records and found that you alone have the right blood type to help. They have therefore kidnapped you, and last night the violinists circulatory system was plugged into yours, so that your kidneys can be used to extract poisons from his blood as well as your own. The director of the hospital now tells you, Look, were sorry the Society of Music Lovers did this to you-we would never have permitted it if we had known. But still, they did it, and the violinist now is plugged into you. To unplug you would be to kill him. But never mind, its only for nine months. By then he will have recovered from his ailment, and can safely be unplugged from you. Is it morally incumbent on you to accede to this situation? No doubt it would be very nice of you if you did, a great kindness. But do you have to accede to it? What if it were not nine months, but nine years? Or longer still? What if the director of the hospital says, Tough luck, I agree, but youve now got to stay in bed, with the vio- linist plugged into you, for the rest of your life. Because remember this. All persons have a right to life, and violinists are persons. Granted you have a right to decide what happens in and to your body, but a persons right to life outweighs your right to decide what happens in and to your body. So you cannot ever be unplugged from him. I imagine you would regard this as outrageous, which suggests that something really is wrong with that plausible-sounding argument I mentioned a moment ago. In this case, of course, you were kidnapped; you didnt volunteer for the operation that plugged the violinist into your kidneys. Can those who oppose abortion on the ground I mentioned make an excep- tion for a pregnancy due to rape? Certainly. They can say that per- sons have a right to life only if they didnt come into existence because of rape; or they can say that all persons have a right to life, but that some have less of a right to life than others, in particular, that those who came into existence because of rape have less. But these state- ments have a rather unpleasant sound. Surely the question of whether you have a right to life at all, or how much of it you have, shouldnt turn on the question of whether or not you are the product of a rape. And in fact the people who oppose abortion on the ground I men- tioned do not make this distinction, and hence do not make an excep- tion in case of rape. This content downloaded from 128.205.114.91 on Thu, 25 Sep 2014 13:20:33 PM All use subject to JSTOR Terms and Conditions http://www.jstor.org/page/info/about/policies/terms.jsp 50 Philosophy & Public Affairs Nor do they make an exception for a case in which the mother has to spend the nine months of her pregnancy in bed. They would agree that would be a great pity, and hard on the mother; but all the same, all persons have a right to life, the fetus is a person, and so on. I sus- pect, in fact, that they would not make an exception for a case in which, miraculously enough, the pregnancy went on for nine years, or even the rest of the mothers life. Some wont even make an exception for a case in which continua- tion of the pregnancy is likely to shorten the mothers life; they regard abortion as impermissible even to save the mothers life. Such cases are nowadays very rare, and many opponents of abortion do not accept this extreme view. All the same, it is a good place to begin: a number of points of interest come out in respect to it. i. Let us call the view that abortion is impermissible even to save the mothers life the extreme view. I want to suggest first that it does not issue from the argument I mentioned earlier without the addition of some fairly powerful premises. Suppose a woman has become preg- nant, and now learns that she has a cardiac condition such that she will die if she carries the baby to term. What may be done for her? The fetus, being a person, has a right to life, but as the mother is a person too, so has she a right to life. Presumably they have an equal right to life. How is it supposed to come out that an abortion may not be performed? If mother and child have an equal right to life, shouldnt we perhaps flip a coin? Or should we add to the mothers right to life her right to decide what happens in and to her body, which everybody seems to be ready to grant-the sum of her rights now outweighing the fetus right to life? The most familiar argument here is the following. We are told that performing the abortion would be directly killing3 the child, whereas doing nothing would not be killing the mother, but only letting her die. Moreover, in killing the child, one would be killing an innocent person, for the child has committed no crime, and is not aiming at his mothers death. And then there are a variety of ways in which this 3. The term direct in the arguments I refer to is a technical one. Roughly, what is meant by direct killing is either killing as an end in itself, or killing as a means to some end, for example, the end of saving someone elses life. See note 6, below, for an example of its use. This content downloaded from 128.205.114.91 on Thu, 25 Sep 2014 13:20:33 PM All use subject to JSTOR Terms and Conditions http://www.jstor.org/page/info/about/policies/terms.jsp 51 A Defense of Abortion might be continued. (i) But as directly killing an innocent person is always and absolutely impermissible, an abortion may not be per- formed. Or, (2) as directly killing an innocent person is murder, and murder is always and absolutely impermissible, an abortion may not be performed.4 Or, (3) as ones duty to refrain from directly killing an innocent person is more stringent than ones duty to keep a person from dying, an abortion may not be performed. Or, (4) if ones only options are, directly killing an innocent person or letting a person die, one must prefer letting the person die, and thus an abortion may not be performed.5 Some people seem to have thought that these are not further prem- ises which must be added if the conclusion is to be reached, but that they follow from the very fact that an innocent person has a right to life.6 But this seems to me to be a mistake, and perhaps the simplest way to show this is to bring out that while we must certainly grant that innocent persons have a right to life, the theses in (i) through (4) are all false. Take (2), for example. If directly killing an inno- cent person is murder, and thus is impermissible, then the mothers directly killing the innocent person inside her is murder, and thus is 4. Cf. Encyclical Letter of Pope Pius XI on Christian Marriage, St. Paul Edi- tions (Boston, n.d.), p. 32: however much we may pity the mother whose health and even life is gravely imperiled in the performance of the duty allotted to her by nature, nevertheless what could ever be a sufficient reason for excusing in any way the direct murder of the innocent? This is precisely what we are dealing with here. Noonan (The Morality of Abortion, p. 43) reads this as follows: What cause can ever avail to excuse in any way the direct killing of the inno- cent? For it is a question of that. 5. The thesis in (4) is in an interesting way weaker than those in (i), (2), and (3): they rule out abortion even in cases in which both mother and child will die if the abortion is not performed. By contrast, one who held the view expressed in (4) could consistently say that one neednt prefer letting two per- sons die to killing one. 6. Cf. the following passage from Pius XII, Address to the Italian Catholic Society of Midwives: The baby in the maternal breast has the right to life imme- diately from God.-Hence there is no man, no human authority, no science, no medical, eugenic, social, economic or moral indication which can establish or grant a valid juridical ground for a direct deliberate disposition of an innocent human life, that is a disposition which looks to its destruction either as an end or as a means to another end perhaps in itself not illicit.-The baby, still not born, is a man in the same degree and for the same reason as the mother (quoted in Noonan, The Morality of Abortion, p. 45). This content downloaded from 128.205.114.91 on Thu, 25 Sep 2014 13:20:33 PM All use subject to JSTOR Terms and Conditions http://www.jstor.org/page/info/about/policies/terms.jsp 52 Philosophy & Public Affairs impermissible. But it cannot seriously be thought to be murder if the mother performs an abortion on herself to save her life. It cannot seriously be said that she must refrain, that she must sit passively by and wait for her death. Let us look again at the case of you and the violinist. There you are, in bed with the violinist, and the director of the hospital says to you, Its all most distressing, and I deeply sym- pathize, but you see this is putting an additional strain on your kid- neys, and youll be dead within the month. But you have to stay where you are all the same. Because unplugging you would be directly kill- ing an innocent violinist, and thats murder, and thats impermissi- ble. If anything in the world is true, it is that you do not commit murder, you do not do what is impermissible, if you reach around to your back and unplug yourself from that violinist to save your life. The main focus of attention in writings on abortion has been on what a third party may or may not do in answer to a request from a woman for an abortion. This is in a way understandable. Things being as they are, there isnt much a woman can safely do to abort herself. So the question asked is what a third party may do, and what the mother may do, if it is mentioned at all, is deduced, almost as an after- thought, from what it is concluded that third parties may do. But it seems to me that to treat the matter in this way is to refuse to grant to the mother that very status of person which is so firmly insisted on for the fetus. For we cannot simply read off what a person may do from what a third party may do. Suppose you find yourself trapped in a tiny house with a growing child. I mean a very tiny house, and a rapidly growing child-you are already up against the wall of the house and in a few minutes youll be crushed to death. The child on the other hand wont be crushed to death; if nothing is done to stop him from growing hell be hurt, but in the end hell simply burst open the house and walk out a free man. Now I could well understand it if a bystander were to say, Theres nothing we can do for you. We cannot choose between your life and his, we cannot be the ones to decide who is to live, we cannot intervene. But it cannot be concluded that you too can do nothing, that you cannot attack it to save your life. However innocent the child may be, you do not have to wait pas- sively while it crushes you to death. Perhaps a pregnant woman is vaguely felt to have the status of house, to which we dont allow the This content downloaded from 128.205.114.91 on Thu, 25 Sep 2014 13:20:33 PM All use subject to JSTOR Terms and Conditions http://www.jstor.org/page/info/about/policies/terms.jsp 53 A Defense of Abortion right of self-defense. But if the woman houses the child, it should be remembered that she is a person who houses it. 1 should perhaps stop to say explicitly that I am not claiming that people have a right to do anything whatever to save their lives. I think, rather, that there are drastic limits to the right of self-defense. If someone threatens you with death unless you torture someone else to death, I think you have not the right, even to save your life, to do so. But the case under consideration here is very different. In our case there are only two people involved, one whose life is threatened, and one who threatens it. Both are innocent: the one who is threatened is not threatened because of any fault, the one who threatens does not threaten because of any fault. For this reason we may feel that we bystanders cannot intervene. But the person threatened can. In sum, a woman surely can defend her life against the threat to it posed by the unborn child, even if doing so involves its death. And this shows not merely that the theses in (i) through (4) are false; it shows also that the extreme view of abortion is false, and so we need not canvass any other possible ways of arriving at it from the argu- ment I mentioned at the outset. 2. The extreme view could of course be weakened to say that while abortion is permissible to save the mothers life, it may not be per- formed by a third party, but only by the mother herself. But this can- not be right either. For what we have to keep in mind is that the mother and the unborn child are not like two tenants in a small house which has, by an unfortunate mistake, been rented to both: the mother owns the house. The fact that she does adds to the offensive- ness of deducing that the mother can do nothing from the supposition that third parties can do nothing. But it does more than this: it casts a bright light on the supposition that third parties can do nothing. Certainly it lets us see that a third party who says I cannot choose between you is fooling himself if he thinks this is impartiality. If Jones has found and fastened on a certain coat, which he needs to keep him from freezing, but which Smith also needs to keep him from freezing, then it is not impartiality that says I cannot choose between you when Smith owns the coat. Women have said again and again This body is my body! and they have reason to feel angry, reason to feel that it has been like shouting into the wind. Smith, after all, is This content downloaded from 128.205.114.91 on Thu, 25 Sep 2014 13:20:33 PM All use subject to JSTOR Terms and Conditions http://www.jstor.org/page/info/about/policies/terms.jsp 54 Philosophy & Public Affairs hardly likely to bless us if we say to him, Of course its your coat, anybody would grant that it is. But no one may choose between you and Jones who is to have it. We should really ask what it is that says no one may choose in the face of the fact that the body that houses the child is the mothers body. It may be simply a failure to appreciate this fact. But it may be something more interesting, namely the sense that one has a right to refuse to lay hands on people, even where it would be just and fair to do so, even where justice seems to require that somebody do so. Thus justice might call for somebody to get Smiths coat back from Jones, and yet you have a right to refuse to be the one to lay hands on Jones, a right to refuse to do physical violence to him. This, I think, must be granted. But then what should be said is not no one may choose, but only I cannot choose, and indeed not even this, but I will not act, leaving it open that somebody else can or should, and in particu- lar that anyone in a position of authority, with the job of securing peoples rights, both can and should. So this is no difficulty. I have not been arguing that any given third party must accede to the moth- ers request that he perform an abortion to save her life, but only that he may. I suppose that in some views of human life the mothers body is only on loan to her, the loan not being one which gives her any prior claim to it. One who held this view might well think it impartiality to say I cannot choose. But I shall simply ignore this possibility. My own view is that if a human being has any just, prior claim to anything at all, he has a just, prior claim to his own body. And perhaps this neednt be argued for here anyway, since, as I mentioned, the argu- ments against abortion we are looking at do grant that the woman has a right to decide what happens in and to her body. But although they do grant it, I have tried to show that they do not take seriously what is done in granting it. I suggest the same thing will reappear even more clearly when we turn away from cases in which the mothers life is at stake, and attend, as I propose we now do, to the vastly more common cases in which a woman wants an abortion for some less weighty reason than preserving her own life. 3. Where the mothers life is not at stake, the argument I men- tioned at the outset seems to have a much stronger pull. Everyone This content downloaded from 128.205.114.91 on Thu, 25 Sep 2014 13:20:33 PM All use subject to JSTOR Terms and Conditions http://www.jstor.org/page/info/about/policies/terms.jsp 55 A Defense of Abortion has a right to life, so the unborn person has a right to life. And isnt the childs right to life weightier than anything other than the moth- ers own right to life, which she might put forward as ground for an abortion? This argument treats the right to life as if it were unproblematic. It is not, and this seems to me to be precisely the source of the mistake. For we should now, at long last, ask what it comes to, to have a right to life. In some views having a right to life includes having a right to be given at least the bare minimum one needs for continued life. But suppose that what in fact is the bare minimum a man needs for continued life is something he has no right at all to be given? If I am sick unto death, and the only thing that will save my life is the touch of Henry Fondas cool hand on my fevered brow, then all the same, I have no right to be given the touch of Henry Fondas cool hand on my fevered brow. It would be frightfully nice of him to fly in from the West Coast to provide it. It would be less nice, though no doubt well meant, if my friends flew out to the West Coast and carried Henry Fonda back with them. But I have no right at all against any- body that he should do this for me. Or again, to return to the story I told earlier, the fact that for continued life that violinist needs the continued use of your kidneys does not establish that he has a right to be given the continued use of your kidneys. He certainly has no right against you that you should give him continued use of your kid- neys. For nobody has any right to use your kidneys unless you give him such a right; and nobody has the right against you that you shall give him this right-if you do allow him to go on using your kidneys, this is a kindness on your part, and not something he can claim from you as his due. Nor has he any right against anybody else that they should give him continued use of your kidneys. Certainly he had no right against the Society of Music Lovers that they should plug him into you in the first place. And if you now start to unplug yourself, having learned that you will otherwise have to spend nine years in bed with him, there is nobody in the world who must try to prevent you, in order to see to it that he is given something he has a right to be given. Some people are rather stricter about the right to life. In their view, it does not include the right to be given anything, but amounts to, This content downloaded from 128.205.114.91 on Thu, 25 Sep 2014 13:20:33 PM All use subject to JSTOR Terms and Conditions http://www.jstor.org/page/info/about/policies/terms.jsp 56 Philosophy & Public Affairs and only to, the right not to be killed by anybody. But here a related difficulty arises. If everybody is to refrain from killing that violinist, then everybody must refrain from doing a great many different sorts of things. Everybody must refrain from slitting his throat, everybody must refrain from shooting him-and everybody must refrain from unplugging you from him. But does he have a right against everybody that they shall refrain from unplugging you from him? To refrain from doing this is to allow him to continue to use your kidneys. It could be argued that he has a right against us that we should allow him to continue to use your kidneys. That is, while he had no right against us that we should give him the use of your kidneys, it might be argued that he anyway has a right against us that we shall not now intervene and deprive him of the use of your kidneys. I shall come back to third-party interventions later. But certainly the violinist has no right against you that you shall allow him to continue to use your kidneys. As I said, if you do allow him to use them, it is a kindness on your part, and not something you owe him. The difficulty I point to here is not peculiar to the right to life. It reappears in connection with all the other natural rights; and it is something which an adequate account of rights must deal with. For present purposes it is enough just to draw attention to it. But I would stress that I am not arguing that people do not have a right to life- quite to the contrary, it seems to me that the primary control we must place on the acceptability of an account of rights is that it should turn out in that account to be a truth that all persons have a right to life. I am arguing only that having a right to life does not guarantee hav- ing either a right to be given the use of or a right to be allowed con- tinued use of another persons body-even if one needs it for life itself. So the right to life will not serve the opponents of abortion in the very simple and clear way in which they seem to have thought it would. 4. There is another way to bring out the difficulty. In the most ordi- nary sort of case, to deprive someone of what he has a right to is to treat him unjustly. Suppose a boy and his small brother are jointly given a box of chocolates for Christmas. If the older boy takes the box and refuses to give his brother any of the chocolates, he is unjust to -him, for the brother has been given a right to half of them. But This content downloaded from 128.205.114.91 on Thu, 25 Sep 2014 13:20:33 PM All use subject to JSTOR Terms and Conditions http://www.jstor.org/page/info/about/policies/terms.jsp 57 A Defense of Abortion suppose that, having learned that otherwise it means nine years in bed with that violinist, you unplug yourself from him. You surely are not being unjust to him, for you gave him no right to use your kid- neys, and no one else can have given him any such right. But we have to notice that in unplugging yourself, you are killing him; and violin- ists, like everybody else, have a right to life, and thus in the view we were considering just now, the right not to be killed. So here you do what he supposedly has a right you shall not do, but you do not act unjustly to him in doing it. The emendation which may be made at this point is this: the right to life consists … -RXUQDO�RI�3KLORVRSK\��,QF� :K\�$ERUWLRQ�LV�,PPRUDO $XWKRU�V���RQ�0DUTXLV 6RXUFH��7KH�-RXUQDO�RI�3KLORVRSK\��9RO������1R�����$SU����������SS��������� 3XEOLVKHG�E\��-RXUQDO�RI�3KLORVRSK\��,QF� 6WDEOH�85/��http://www.jstor.org/stable/2026961 . $FFHVVHG������������������ Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at . http://www.jstor.org/page/info/about/policies/terms.jsp . JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact [email protected] . Journal of Philosophy, Inc. is collaborating with JSTOR to digitize, preserve and extend access to The Journal of Philosophy. http://www.jstor.org This content downloaded from 128.205.114.91 on Thu, 25 Sep 2014 13:21:31 PM All use subject to JSTOR Terms and Conditions http://www.jstor.org/action/showPublisher?publisherCode=jphil http://www.jstor.org/stable/2026961?origin=JSTOR-pdf http://www.jstor.org/page/info/about/policies/terms.jsp http://www.jstor.org/page/info/about/policies/terms.jsp WHY ABORTION IS IMMORAL 183 WHY ABORTION IS IMMORAL T n HE view that abortion is, with rare exceptions, seriously im- moral has received little support in the recent philosophical literature. No doubt most philosophers affiliated with secular institutions of higher education believe that the anti-abortion posi- tion is either a symptom of irrational religious dogma or a conclusion generated by seriously confused philosophical argument. The pur- pose of this essay is to undermine this general belief. This essay sets out an argument that purports to show, as well as any argument in ethics can show, that abortion is, except possibly in rare cases, seri- ously immoral, that it is in the same moral category as killing an innocent adult human being. The argument is based on a major assumption. Many of the most insightful and careful writers on the ethics of abortion-such as Joel Feinberg, Michael Tooley, Mary Anne Warren, H. Tristram Engel- hardt, Jr., L. W. Sumner, John T. Noonan, Jr., and Philip Devine- believe that whether or not abortion is morally permissible stands or falls on whether or not a fetus is the sort of being whose life it is seriously wrong to end. The argument of this essay will assume, but not argue, that they are correct. Also, this essay will neglect issues of great importance to a complete ethics of abortion. Some anti-abortionists will allow that certain abortions, such as abortion before implantation or abortion when the life of a woman is threatened by a pregnancy or abortion after rape, may be morally permissible. This essay will not explore the casuistry of these hard cases. The purpose of this essay is to develop a general argument for the claim that the overwhelming majority of deliberate abortions are seriously immoral. I. A sketch of standard anti-abortion and pro-choice arguments ex- hibits how those arguments possess certain symmetries that explain why partisans of those positions are so convinced of the correctness of their own positions, why they are not successful in convincing Feinberg, Abortion, in Matters of Life and Death: New Introductory Essays in Moral Philosophy, Tom Regan, ed. (New York: Random House, 1986), pp. 256-293; Tooley, Abortion and Infanticide, Philosophy and Public Affairs, ii, 1 (1972):37-65, Tooley, Abortion and Infanticide (New York: Oxford, 1984); War- ren, On the Moral and Legal Status of Abortion, The Monist, I.vii, 1 (1973):43- 61; Engelhardt, The Ontology of Abortion, Ethics, lxxxiv, 3 (1974):217-234; Sumner, Abortion and Moral Theory (Princeton: University Press, 1981); Noonan, An Almost Absolute Value in History, in The Morality of Abortion: Legal and Historical Perspectives, Noonan, ed. (Cambridge: Harvard, 1970); and Devine, The Ethics of Homicide (Ithaca: Cornell, 1978). 0022-362X /89/8604/183-22 (? 1989 The Journal of Philosophy, Inc. This content downloaded from 128.205.114.91 on Thu, 25 Sep 2014 13:21:31 PM All use subject to JSTOR Terms and Conditions http://www.jstor.org/page/info/about/policies/terms.jsp 184 THE JOURNAL OF PHILOSOPHY their opponents, and why, to others, this issue seems to be unresolv- able. An analysis of the nature of this standoff suggests a strategy for surmounting it. Consider the way a typical anti-abortionist argues. She will argue or assert that life is present from the moment of conception or that fetuses look like babies or that fetuses possess a characteristic such as a genetic code that is both necessary and sufficient for being human. Anti-abortionists seem to believe that (1) the truth of all of these claims is quite obvious, and (2) establishing any of these claims is sufficient to show that abortion is morally akin to murder. A standard pro-choice strategy exhibits similarities. The pro- choicer will argue or assert that fetuses are not persons or that fetuses are not rational agents or that fetuses are not social beings. Pro-choicers seem to believe that (1) the truth of any of these claims is quite obvious, and (2) establishing any of these claims is sufficient to show that an abortion is not a wrongful killing. In fact, both the pro-choice and the anti-abortion claims do seem to be true, although the it looks like a baby claim is more difficult to establish the earlier the pregnancy. We seem to have a standoff. How can it be resolved? As everyone who has taken a bit of logic knows, if any of these arguments concerning abortion is a good argument, it requires not only some claim characterizing fetuses, but also some general moral principle that ties a characteristic of fetuses to having or not having the right to life or to some other moral characteristic that will gener- ate the obligation or the lack of obligation not to end the life of a fetus. Accordingly, the arguments of the anti-abortionist and the pro-choicer need a bit of filling in to be regarded as adequate. Note what each partisan will say. The anti-abortionist will claim that her position is supported by such generally accepted moral principles as It is always prima facie seriously wrong to take a human life or It is always prima facie seriously wrong to end the life of a baby. Since these are generally accepted moral principles, her position is certainly not obviously wrong. The pro-choicer will claim that her position is supported by such plausible moral princi- ples as Being a person is what gives an individual intrinsic moral worth or It is only seriously prima facie wrong to take the life of a member of the human community. Since these are generally ac- cepted moral principles, the pro-choice position is certainly not ob- viously wrong. Unfortunately, we have again arrived at a standoff. Now, how might one deal with this standoff? The standard ap- proach is to try to show how the moral principles of ones opponent lose their plausibility under analysis. It is easy to see how this is This content downloaded from 128.205.114.91 on Thu, 25 Sep 2014 13:21:31 PM All use subject to JSTOR Terms and Conditions http://www.jstor.org/page/info/about/policies/terms.jsp WHY ABORTION IS IMMORAI, 185 possible. On the one hand, the anti-abortionist will defend a moral principle concerning the wrongness of killing which tends to be broad in scope in order that even fetuses at an early stage of preg- nancy will fall under it. The problem with broad principles is that they often embrace too much. In this particular instance, the princi- ple It is always prima facie wrong to take a human life seems to entail that it is wrong to end the existence of a living human cancer- cell culture, on the grounds that the culture is both living and human. Therefore, it seems that the anti-abortionists favored princi- ple is too broad. On the other hand, the pro-choicer wants to find a moral principle concerning the wrongness of killing which tends to be narrow in scope in order that fetuses will not fall under it. The problem with narrow principles is that they often do not embrace enough. Hence, the needed principles such as It is prima facie seriously wrong to kill only persons or It is prima facie wrong to kill only rational agents do not explain why it is wrong to kill infants or young children or the severely retarded or even perhaps the severely mentally ill. There- fore, we seem again to have a standoff. The anti-abortionist charges, not unreasonably, that pro-choice principles concerning killing are too narrow to be acceptable; the pro-choicer charges, not unreason- ably, that anti-abortionist principles concerning killing are too broad to be acceptable. Attempts by both sides to patch up the difficulties in their posi- tions run into further difficulties. The anti-abortionist will try to remove the problem in her position by reformulating her principle concerning killing in terms of human beings. Now we end up with: It is always prima facie seriously wrong to end the life of a human being. This principle has the advantage of avoiding the problem of the human cancer-cell culture counterexample. But this advantage is purchased at a high price. For although it is clear that a fetus is both human and alive, it is not at all clear that a fetus is a human being. There is at least something to be said for the view that something becomes a human being only after a process of development, and that therefore first trimester fetuses and perhaps all fetuses are not yet human beings. Hence, the anti-abortionist, by this move, has merely exchanged one problem for another.2 The pro-choicer fares no better. She may attempt to find reasons why killing infants, young children, and the severely retarded is 2 For interesting discussions of this issue, see Warren Quinn, Abortion: Identity and Loss, Philosophy and Public Affairs, xiii, 1 (1984):24-54; and Lawrence C. Becker, Human Being: The Boundaries of the Concept, Philosophy and Public Affairs, iv, 4 (1975):334-359. This content downloaded from 128.205.114.91 on Thu, 25 Sep 2014 13:21:31 PM All use subject to JSTOR Terms and Conditions http://www.jstor.org/page/info/about/policies/terms.jsp 186 THE JOURNAL OF PHILOSOPHY wrong which are independent of her major principle that is sup- posed to explain the wrongness of taking human life, but which will not also make abortion immoral. This is no easy task. Appeals to social utility will seem satisfactory only to those who resolve not to think of the enormous difficulties with a utilitarian account of the wrongness of killing and the significant social costs of preserving the lives of the unproductive.3 A pro-choice strategy that extends the definition of person to infants or even to young children seems just as arbitrary as an anti-abortion strategy that extends the definition of human being to fetuses. Again, we find symmetries in the two posi- tions and we arrive at a standoff. There are even further problems that reflect symmetries in the two positions. In addition to counterexample problems, or the arbitrary application problems that can be exchanged for them, the standard anti-abortionist principle It is prima facie seriously wrong to kill a human being, or one of its variants, can be objected to on the grounds of ambiguity. If human being is taken to be a biological category, then the anti-abortionist is left with the problem of ex- plaining why a merely biological category should make a moral dif- ference. Why, it is asked, is it any more reasonable to base a moral conclusion on the number of chromosomes in ones cells than on the color of ones skin?4 If human being, on the other hand, is taken to be a moral category, then the claim that a fetus is a human being cannot be taken to be a premise in the anti-abortion argument, for it is precisely what needs to be established. Hence, either the anti- abortionists main category is a morally irrelevant, merely biological category, or it is of no use to the anti-abortionist in establishing (noncircularly, of course) that abortion is wrong. Although this problem with the anti-abortionist position is often noticed, it is less often noticed that the pro-choice position suffers from an analogous problem. The principle Only persons have the right to life also suffers from an ambiguity. The term person is typically defined in terms of psychological characteristics, although there will certainly be disagreement concerning which characteristics are most important. Supposing that this matter can be settled, the pro-choicer is left with the problem of explaining why psychological characteristics should make a moral difference. If the pro-choicer should attempt to deal with this problem by claiming that an explana- For example, see my Ethics and The Elderly: Some Problems, in Stuart Spicker, Kathleen Woodward, and David Van Tassel, eds., Aging and the Elderly: Humanistic Perspectives in Gerontology (Atlantic Highlands, NJ: Humanities, 1978), pp. 341-355. 4See Warren, op. cit., and Tooley, Abortion and Infanticide. This content downloaded from 128.205.114.91 on Thu, 25 Sep 2014 13:21:31 PM All use subject to JSTOR Terms and Conditions http://www.jstor.org/page/info/about/policies/terms.jsp WHY ABORTION IS IMMORAL 187 tion is not necessary, that in fact we do treat such a cluster of psycho- logical properties as having moral significance, the sharp-witted anti-abortionist should have a ready response. We do treat being both living and human as having moral significance. If it is legitimate for the pro-choicer to demand that the anti-abortionist provide an explanation of the connection between the biological character of being a human being and the wrongness of being killed (even though people accept this connection), then it is legitimate for the anti- abortionist to demand that the pro-choicer provide an explanation of the connection between psychological criteria for being a person and the wrongness of being killed (even though that connection is accepted). 5 Feinberg has attempted to meet this objection (he calls psychologi- cal personhood commonsense personhood): The characteristics that confer commonsense personhood are not arbi- trary bases for rights and duties, such as race, sex or species member- ship; rather they are traits that make sense out of rights and duties and without which those moral attributes would have no point or function. It is because people are conscious; have a sense of their personal identities; have plans, goals, and projects; experience emotions; are liable to pains, anxieties, and frustrations; can reason and bargain, and so on-it is because of these attributes that people have values and interests, desires and expectations of their own, including a stake in their own futures, and a personal well-being of a sort we cannot ascribe to unconscious or nonrational beings. Because of their developed capacities they can as- sume duties and responsibilities and can have and make claims on one another. Only because of their sense of self, their life plans, their value hierarchies, and their stakes in their own futures can they be ascribed fundamental rights. There is nothing arbitrary about these linkages (op. cit., p. 270). The plausible aspects of this attempt should not be taken to obscure its implausible features. There is a great deal to be said for the view that being a psychological person under some description is a neces- sary condition for having duties. One cannot have a duty unless one is capable of behaving morally, and a beings capability of behaving morally will require having a certain psychology. It is far from obvi- ous, however, that having rights entails consciousness or rationality, as Feinberg suggests. We speak of the rights of the severely retarded or the severely mentally ill, yet some of these persons are not ra- tional. We speak of the rights of the temporarily unconscious. The New Jersey Supreme Court based their decision in the Quinlan case This seems to be the fatal flaw in Warrens treatment of this issue. This content downloaded from 128.205.114.91 on Thu, 25 Sep 2014 13:21:31 PM All use subject to JSTOR Terms and Conditions http://www.jstor.org/page/info/about/policies/terms.jsp 188 THE JOURNAL OF PHILOSOPHY on Karen Ann Quinlans right to privacy, and she was known to be permanently unconscious at that time. Hence, Feinbergs claim that having rights entails being conscious is, on its face, obviously false. Of course, it might not make sense to attribute rights to a being that would never in its natural history have certain psychological traits. This modest connection between psychological personhood and moral personhood will create a place for Karen Ann Quinlan and the temporarily unconscious. But then it makes a place for fetuses also. Hence, it does not serve Feinbergs pro-choice pur- poses. Accordingly, it seems that the pro-choicer will have as much difficulty bridging the gap between psychological personhood and personhood in the moral sense as the anti-abortionist has bridging the gap between being a biological human being and being a human being in the moral sense. Furthermore, the pro-choicer cannot any more escape her prob- lem by making person a purely moral category than the anti-abor- tionist could escape by the analogous move. For if person is a moral category, then the pro-choicer is left without the resources for es- tablishing (noncircularly, of course) the claim that a fetus is not a person, which is an essential premise in her argument. Again, we have both a symmetry and a standoff between pro-choice and anti- abortion views. Passions in the abortion debate run high. There are both plausi- bilities and difficulties with the standard positions. Accordingly, it is hardly surprising that partisans of either side embrace with fervor the moral generalizations that support the conclusions they preana- lytically favor, and reject with disdain the moral generalizations of their opponents as being subject to inescapable difficulties. It is easy to believe that the counterexamples to ones own moral principles are merely temporary difficulties that will dissolve in the wake of further philosophical research, and that the counterexamples to the principles of ones opponents are as straightforward as the contra- diction between A and 0 propositions in traditional logic. This might suggest to an impartial observer (if there are any) that the abortion issue is unresolvable. There is a way out of this apparent dialectical quandary. The moral generalizations of both sides are not quite correct. The generaliza- tions hold for the most part, for the usual cases. This suggests that they are all accidental generalizations, that the moral claims made by those on both sides of the dispute do not touch on the essence of the matter. This use of the distinction between essence and accident is not meant to invoke obscure metaphysical categories. Rather, it is in- This content downloaded from 128.205.114.91 on Thu, 25 Sep 2014 13:21:31 PM All use subject to JSTOR Terms and Conditions http://www.jstor.org/page/info/about/policies/terms.jsp WHY ABORTION IS IMMORAL 189 tended to reflect the rather atheoretical nature of the abortion dis- cussion. If the generalization a partisan in the abortion dispute adopts were derived from the reason why ending the life of a human being is wrong, then there could not be exceptions to that general- ization unless some special case obtains in which there are even more powerful countervailing reasons. Such generalizations would not be merely accidental generalizations; they would point to, or be based upon, the essence of the wrongness of killing, what it is that makes killing wrong. All this suggests that a necessary condition of resolving the abortion controversy is a more theoretical account of the wrongness of killing. After all, if we merely believe, but do not un- derstand, why killing adult human beings such as ourselves is wrong, how could we conceivably show that abortion is either immoral or permissible? II. In order to develop such an account, we can start from the following unproblematic assumption concerning our own case: it is wrong to kill us. Why is it wrong? Some answers can be easily eliminated. It might be said that what makes killing us wrong is that a killing bruta- lizes the one who kills. But the brutalization consists of being inured to the performance of an act that is hideously immoral; hence, the brutalization does not explain the immorality. It might be said that what makes killing us wrong is the great loss others would experience due to our absence. Although such hubris is understandable, such an explanation does not account for the wrongness of killing hermits, or those whose lives are relatively independent and whose friends find it easy to make new friends. A more obvious answer is better. What primarily makes killing wrong is neither its effect on the murderer nor its effect on the victims friends and relatives, but its effect on the victim. The loss of ones life is one of the greatest losses one can suffer. The loss of ones life deprives one of all the experiences, activities, projects, and en- joyments that would otherwise have constituted ones future. There- fore, killing someone is wrong, primarily because the killing inflicts (one of) the greatest possible losses on the victim. To describe this as the loss of life can be misleading, however. The change in my biologi- cal state does not by itself make killing me wrong. The effect of the loss of my biological life is the loss to me of all those activities, projects, experiences, and enjoyments which would otherwise have constituted my future personal life. These activities, projects, experi- ences, and enjoyments are either valuable for their own sakes or are means to something else that is valuable for its own sake. Some parts of my future are not valued by me now, but will come to be valued by This content downloaded from 128.205.114.91 on Thu, 25 Sep 2014 13:21:31 PM All use subject to JSTOR Terms and Conditions http://www.jstor.org/page/info/about/policies/terms.jsp 190 THE JOURNAL OF PHILOSOPHY me as I grow older and as my values and capacities change. When I am killed, I am deprived both of what I now value which would have been part of my future personal life, but also what I would come to value. Therefore, when I die, I am deprived of all of the value of my future. Inflicting this loss on me is ultimately what makes killing me wrong. This being the case, it would seem that what makes killing any adult human being prima facie seriously wrong is the loss of his or her future.6 How should this rudimentary theory of the wrongness of killing be evaluated? It cannot be faulted for deriving an ought from an is, for it does not. The analysis assumes that killing me (or you, reader) is prima facie seriously wrong. The point of the analysis is to establish which natural property ultimately explains the wrongness of the kill- ing, given that it is wrong. A natural property will ultimately explain the wrongness of killing, only if (1) the explanation fits with our intuitions about the matter and (2) there is no other natural property that provides the basis for a better explanation of the wrongness of killing. This analysis rests on the intuition that what makes killing a particular human or animal wrong is what it does to that particular human or animal. What makes killing wrong is some natural effect or other of the killing. Some would deny this. For instance, a divine- command theorist in ethics would deny it. Surely this denial is, how- ever, one of those features of divine-command theory which renders it so implausible. The claim that what makes killing wrong is the loss of the victims future is, directly supported by two considerations. In the first place, this theory explains why we regard killing as one of the worst of crimes. Killing is especially wrong, because it deprives the victim of more than perhaps any other crime. In the second place, people with AIDS or cancer who know they are dying believe, of course, that dying is a very bad thing for them. They believe that the loss of a future to them that they would otherwise have experienced is what makes their premature death a very bad thing for them. A better theory of the wrongness of killing would require a different natural property associated with killing which better fits with the attitudes of the dying. What could it be? The view that what makes killing wrong is the loss to the victim of the value of the victims future gains additional support when some of its implications are examined. In the first place, it is incompatible h I have been most influenced on this matter byJonathan Glover, Causing Death and Saving Lives (New York: Penguin, 1977), ch. 3; and Robert Young, What Is So Wrong with Killing People? Philosophy, l iv, 210 (1979):515-528. This content downloaded from 128.205.114.91 on Thu, 25 Sep 2014 13:21:31 PM All use subject to JSTOR Terms and Conditions http://www.jstor.org/page/info/about/policies/terms.jsp WHY ABORTION IS IMMORAL 191 with the view that it is wrong to kill only beings who are biologically human. It is possible that there exists a different species from an- other planet whose members have a future like ours. Since having a future like that is what makes killing someone wrong, this theory entails that it would be wrong to kill members of such a species. Hence, this theory is opposed to the claim that only life that is biologically human has great moral worth, a claim which many anti- abortionists have seemed to adopt. This opposition, which this theory has in common with personhood theories, seems to be a merit of the theory. In the second place, the claim that the loss of ones future is the wrong-making feature of ones being killed entails the possibility that the futures of some actual nonhuman mammals on our own planet are sufficiently like ours that it is seriously wrong to kill them also. Whether some animals do have the same right to life as human beings depends on adding to the account of the wrongness of killing some additional account ofjust what it is about my future or the futures of other adult human beings which makes it wrong to kill us. No such additional account will be offered in this essay. Undoubtedly, the provision of such an account would be a very difficult matter. Un- doubtedly, any such account would be quite controversial. Hence, it surely should not reflect badly on this sketch of an elementary theory of the wrongness of killing that it is indeterminate with respect to some very difficult issues regarding animal rights. In the third place, the claim that the loss of ones future is the wrong-making feature of ones being killed does not entail, as sanc- tity of human life theories do, that active euthanasia is wrong. Per- sons who are severely and incurably ill, who face a future of pain and despair, and who wish to die will not have suffered a loss if they are killed. It is, strictly speaking, the value of a humans future which makes killing wrong in this theory. This being so, killing does not necessarily wrong some persons who are sick and dying. Of course, there may be other reasons for a prohibition of active euthanasia, but that is another matter. Sanctity-of-human-life theories seem to hold that active euthanasia is seriously wrong even in an individual case where there seems to be good reason for it independently of public policy considerations. This consequence is most implausible, and it is a plus for the claim that the loss of a future of value is what makes killing wrong that it does not share this consequence. In the fourth place, the account of the wrongness of killing de- fended in this essay does straightforwardly entail that it is prima facie seriously wrong to kill children and infants, for we do presume that they have futures of value. Since we do believe that it is wrong to kill This content downloaded from 128.205.114.91 on Thu, 25 Sep 2014 13:21:31 PM All use subject to JSTOR Terms and Conditions http://www.jstor.org/page/info/about/policies/terms.jsp 192 THE JOURNAL OF PHILOSOPHY defenseless little babies, it is important that a theory of … Challenges to Human Equality Author(s): Jeff McMahan Source: The Journal of Ethics, Vol. 12, No. 1 (2008), pp. 81-104 Published by: Springer Stable URL: http://www.jstor.org/stable/40345340 Accessed: 22-08-2016 20:32 UTC REFERENCES Linked references are available on JSTOR for this article: http://www.jstor.org/stable/40345340?seq=1&cid=pdf-reference#references_tab_contents You may need to log in to JSTOR to access the linked references. Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at http://about.jstor.org/terms JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact [email protected] Springer is collaborating with JSTOR to digitize, preserve and extend access to The Journal of Ethics This content downloaded from 128.205.114.91 on Mon, 22 Aug 2016 20:32:58 UTC All use subject to http://about.jstor.org/terms JEFF MCMAHAN CHALLENGES TO HUMAN EQUALITY (Received 9 July 2006; accepted in revised form 9 July 2006) ABSTRACT. According to liberal egalitarian morality, all human beings are one anothers moral equals. Nonhuman animals, by contrast, are not considered to be our moral equals. This essay considers two challenges to the liberal egalitarian view. One is the separation problem, which is the challenge to identify a morally significant intrinsic difference between a//human beings and all nonhuman animals. The other is the equality problem, which is to explain how all human beings can be morally equal when there are some human beings whose psychological capacities (and, in some cases, their psycho- logical potentials as well) are no higher than those of certain nonhuman animals. The focus throughout is on the ethics of killing but the arguments are of broader relevance. The essay reaches a skeptical conclusion about our ability to meet these challenges. KEY WORDS: animals, cognitive disability, equality, killing 1. The Separation Problem In contemporary Western societies, common sense morality is liberal egalitarian in character. With the possible exception of human beings in their embryonic or fetal stages, all human beings are recognized - in principle if not in practice - as one anothers moral equals. Each human being matters equally; each has equal value and equal human rights. One element of this liberal egalitarian view is the belief that all wrongful killings of human beings are equally wrong, except, perhaps, when there are relevant differences in the state of the agent, such as the difference between a killing that the agent intends and one that the agent merely foresees as a side effect of his action.1 In the book 1 The object of evaluation here is the causing of a human being to cease to exist, not the manner in which the human being is killed. It may well be more seriously wrong to kill a person in an agonizing manner than to kill the same person painlessly. But this is because the former involves two distinct wrongs: causing the agony and causing the death. The claim of equal wrongness applies to the causing of death alone. The Journal of Ethics (2008) 12:81-104 DOI 10.1007/sl0892-007-9020-9 © Springer 2007 This content downloaded from 128.205.114.91 on Mon, 22 Aug 2016 20:32:58 UTC All use subject to http://about.jstor.org/terms 82 CHALLENGES TO HUMAN EQUALITY ably and generously reviewed by Rahul Kumar in the preceding article, I discussed a more restricted view, which I called the equal wrongness thesis.2 The equal wrongness thesis applies not to all wrongful killings of human beings but only to wrongful killings of persons - that is, individuals with psychological capacities beyond a certain threshold of self-consciousness and minimal rationality. According to the equal wrongness thesis, the extent to which it is wrong to kill a person is unaffected by facts about the victim other than those that may make him or her liable to be killed, or deserve to be killed, if indeed it is possible for a person to deserve to be killed - that is, facts other than those that may make the victim non-innocent in the relevant sense. It is, according to the equal wrongness thesis, no less seriously wrong to kill an old person than to kill a young person, or to kill a person of melancholy disposition than to kill a person with a happy temperament. The extent to which it is wrong to kill a person is, in short, unaffected by the degree of loss or harm he would suffer by being killed. Provided that he satisfies the criteria of personhood, the wrongness of killing him is also unaffected by his nature or capacities - for example, by whether he is virtuous or vicious, likable or obnoxious, sensitive or insensitive, intelligent or unintelligent, and so on. In the book, I neither endorsed nor challenged the equal wrongness thesis, though my discussion of it was respectful and I assumed it to be true for the sake of argument. Most liberals insist that decisions not only about killing but even about saving lives must not be based on quality of life consider- ations, or quantity of life considerations. There is, however, some disagreement about this, even among liberals, in cases other than those involving wrongful killing. Some accept that when one can save some but not all the people who will otherwise die, it can be permissible, at least in some instances, to give priority to those who would lose most by dying. And some accept that this can be permissible as well in choices of whom to kill when circumstances make it permissible to kill someone. Suppose, for example, that that a runaway train is on a track leading to the station where another train full of passengers has stopped. If nothing is done, the runaway train will crash into the stationary train, killing hundreds of people. But the train can be diverted onto one of two branching tracks before it reaches the station. On one of these tracks there is a 20-year-old who 2 Jeff McMahan, The Ethics of Killing: Problems at the Margins of Life (Oxford: Oxford University Press, 2002), pp. 233-248. This content downloaded from 128.205.114.91 on Mon, 22 Aug 2016 20:32:58 UTC All use subject to http://about.jstor.org/terms JEFF MCMAHAN 83 cannot get off, while on the other there is a 90-year-old who cannot get off. Most of us believe that it would be permissible to divert the train onto one of the two tracks. Some liberals accept that it would be permissible, or perhaps even required, to choose to kill the older person on the ground that she would lose less by being killed, if there were no weightier considerations that favored killing the younger person instead. But many liberals believe that even in this kind of case, equality requires that each of the two potential victims be given an equal chance of surviving, so that, ideally, a randomizing device, such as flipping a coin, should be used to determine onto which track the train should be diverted. These people believe that a killing that would be permissible if the choice of victim were made randomly would be wrongful if the choice were made on the basis of a comparison between the potential victims characteristics. The equal wrongness thesis, which applies to wrongful killings of persons, is deeply intuitive. Yet it is too weak to capture most peoples intuitions, which extend the scope of equality beyond persons to include all human beings, or at least all postnatal human beings. Almost no one, however, believes that nonhuman animals are our moral equals or have rights equal to ours. They are by definition ineligible for human rights. And virtually everyone agrees that killing an animal cannot be as seriously wrong as killing an innocent human being, or a person. Not only are animals not our equals, but they are not even equal among themselves; thus it is regarded as more seriously wrong to kill a higher nonhuman animal, such as a chimpanzee, than it is to kill a lower animal, such as a lizard. When pressed to explain why animals lie outside the scope of liberal egalitarian principles, such as the equal wrongness thesis, that are thought to govern our treatment of other human beings, most liberals respond initially by appealing to certain psychological capacities that human beings possess but that animals lack. Human beings, they point out, have capacities for self-consciousness, rationality, autonomy, the use of language, action on the basis of reasons, and so on. Some one or combination of these capacities is what relevantly distinguishes human beings from animals and provides the foundation for human equality. Yet according to the common understanding of what it is to have a capacity, some human beings lack all such capacities. Some, such as the severely demented and the irreversibly comatose, lack them now but had them in the past. Others, such as most fetuses and newborn infants, lack them This content downloaded from 128.205.114.91 on Mon, 22 Aug 2016 20:32:58 UTC All use subject to http://about.jstor.org/terms 84 CHALLENGES TO HUMAN EQUALITY now but have the potential to have them in the future.3 But some human beings - namely, those that are congenitally and radically cognitively impaired - have never had the capacities and also seem to lack the potential to have them. And even among those human beings who possess some of the capacities, there are some who do not possess them all, while among those who possess them all, there are some in whom the relevant capacities are more highly developed than they are in others. How, then, can such capacities provide a basis for human equality? There are here two related but distinguishable problems for liberal egalitarianism. One is to defend the common sense view that all human beings are owed a form of consideration that is different from and higher than that which is owed to other animals. The other is to show how that form of consideration can be owed equally to all human beings. I will call these the separation problem and the equality problem, respectively. I believe that the separation problem cannot be solved. If some individuals are owed a higher form of consideration than is owed to any animal, that must be because they have certain higher psychological capacities. An acceptable form of separation may place most human beings above a relevant threshold of psychological capacity, but it will leave some human beings below it and may place some nonhuman animals above it. And if the threshold is defined by psychological capacity, the equality problem will remain, though not with respect to all human beings but with respect to all those individuals above the relevant threshold. Most philosophers believe that both these problems for liberal egalitarianism can be solved. They believe that we can identify a basis for distinguishing morally between human beings and nonhuman animals that is not variable. They accept the relevance of psychological capacities but claim that, while possession of higher psychological capacities is sufficient for inclusion within the scope of liberal egalitarian principles, such as the equal wrongness thesis, it is not necessary. Human beings who lack the relevant capacities may nevertheless be within the scope of the principles by virtue of having a closely related characteristic. This type of response is defended by Kumar, who contends that claims about the life-cycle of a particular 3 Liberal egalitarians who believe that abortion can be permissible may take the fact that fetuses lack the relevant capacities as partial confirmation that it is these capacities that distinguish most human beings from other animals. But if so, they have a problem if they share the common opposition to infanticide (See Jeff McMahan, Infanticide, Utilitas, forthcoming). This content downloaded from 128.205.114.91 on Mon, 22 Aug 2016 20:32:58 UTC All use subject to http://about.jstor.org/terms JEFF MCMAHAN 85 kind of living thing, or species, are just constitutive of what it is to be a member of that species and that liberal egalitarian principles are responsive, not just to the particular properties of an individual, but to the characteristic life-cycle of the species to which that individual belongs.4 There are two ways in which Kumars remarks can be interpreted. In one passage he writes that claims about species are not statistical generalizations. Rather, what they concern is the essential nature of a living kind, revealing facts about the normal life-cycle of that kind of living thing. The use of normal here is unashamedly normative. ... What respect for the value of a living thing requires will depend on the charac- teristic life-cycle, or nature, of members of that [individuals] species.5 This passage suggests that in order to have the same moral status as a normal human being, it is not necessary for an individual actually to have a rational nature or to be internally directed toward the development of a rational nature. Instead, these properties are normatively characteristic of human beings - that is, all human beings ought to have them even if there are some that do not. Because of this, those human beings who will not have the normal or characteristic human life-cycle, or who do not have the nature characteristic of human beings, must nevertheless be accorded the same respect that would be due to them if they did. This view raises the question why facts about the nature of some individuals could determine how other individuals that lack that nature ought to be treated. Somehow membership in the same biological kind is supposed to produce the requisite moral alchemy, but it is opaque to me how this is supposed to work. I will not, however, pursue this issue further here, as I have done so elsewhere.6 I will also not address certain other questions raised by this interpretation, such as whether there is any basis for what is normatively characteristic of a species other than what is statistically characteristic of it, and, if not, why we should suppose that what is statistically characteristic is invested with normative significance. I will focus instead on a second interpretation of Kumars view. According to this interpretation, what Kumar claims is that all human beings are equal in their possession of the essential nature of human 4 Rahul Kumar, Permissible Killing and the Irrelevance of Being Human, The Journal of Ethics, this issue (cited from two different paragraphs). Emphasis added. 5 Kumar, Permissible Killing and the Irrelevance of Being Human. 6 Jeff McMahan, Our Fellow Creatures, The Journal of Ethics 9 (2005), pp. 355-359. This content downloaded from 128.205.114.91 on Mon, 22 Aug 2016 20:32:58 UTC All use subject to http://about.jstor.org/terms 86 CHALLENGES TO HUMAN EQUALITY beings - the nature that defines their characteristic life-cycle and includes having (or, perhaps, having had) a capacity for rational self- governance, or being internally directed toward the development of such a capacity.1 It is the possession of this essential nature that brings all human beings within the scope of liberal egalitarian principles. This view has much to recommend it. If successful, it brings all human beings within the scope of liberal egalitarian principles, while excluding all or most nonhuman animals. This does not mean, however, that the view is committed to endorsing common sense moralitys assignment of a vastly lower status to animals. It could deny that most animals are our moral equals and yet concede that perhaps some few of the higher animals are, while claiming that others are worthy of significantly better treatment than they are accorded by current practices. Admittedly, the view would disqualify liberals who defend the permissibility of abortion from appealing for support to claims about fetal status, such as the claim that fetuses are not persons; yet these liberals could, as Kumar suggests, appeal to arguments that focus instead on the fetuss lack of a right to the use of the pregnant womans body as a means of life support. Unlike arguments for abortion that appeal to fetal status, this sort of argument has no tendency to support the permissibility of infanticide - surely an advantage if we want to preserve deeply held intuitions. Many of Kumars claims refer at least implicitly to biologically immature human beings that lack the present capacity for rational self-governance but nevertheless have the potential to develop that capacity. He claims that respecting these individuals nature as human beings involves not impeding and even facilitating the full realization of their potential and thus their essential nature. In the case of a human being that in a clear sense lacks even the potential for rational self-governance, such as a fetus with defective genes that direct the growth of the brain, he believes that respecting its nature involves providing that potential if possible - for example, by supplying it with properly functional genes for brain growth. For given its nature as a human being, its lack of those genes is a 7 Kumar, Permissible Killing and the Irrelevance of Being Human. For a similar view, see Robert P. George and Alfonso Gomez-Lobo, Statement of Pro- fessor George (Joined by Dr. Gomez-Lobo), an appendix to Human Cloning and Human Dignity: An Ethical Inquiry, a report by the Presidents Council on Bioethics, available at http://www.bioethics.gov/topics/cloningjndex.html (accessed on 30 June 2006). And compare S. Matthew Liao, Virtually All Human Beings as Rightholders, unpublished manuscript. This content downloaded from 128.205.114.91 on Mon, 22 Aug 2016 20:32:58 UTC All use subject to http://about.jstor.org/terms JEFF MCMAHAN 87 misfortune, though the absence of those genes, and the associated apparent lack of potential for rational self-governance, are not misfortunes for a nonhuman animal. There is a challenge here that I have not adequately addressed either in my book or in a recent article in The Journal of Ethics in which I advanced various arguments against views, such as Kumars, that claim that the morality of our treatment of an individual ought to be... guided by the moral norms that regulate how members of that individuals species ought to be treated.8 The challenge derives from the view that the reason why all human beings are included within the scope of liberal egalitarian principles, such as the equal wrongness thesis, is that they all have, as part of their essential nature or constitution at all times at which they exist, either certain higher psychological capacities, such as the capacity for rational self- governance, or an inner directedness toward the possession or development of those capacities. On this view, membership in the human species is not morally significant only, or primarily, or perhaps at all, because it involves a significant relation to other human beings. It is significant because it is sufficient for the possession of an intrinsically significant nature, whether or not that nature is fully realized.9 Most mature human beings have a rational nature and most immature human beings do seem to be inherently or internally directed toward the development of the capacity for rationality. Suppose we grant - what I believe to be plausible - that the actual 8 Kumar, Permissible Killing and the Irrelevance of Being Human. See McMahan, Our Fellow Creatures. 9 What about human beings who once had higher psychological capacities but have irreversibly lost them? There are two ways in which this view can attempt to accommodate such individuals within the scope of liberal egalitarian principles. One is to claim that even if the acquisition of a certain moral status requires the possession of or potential for certain capacities, that status can nevertheless survive the loss of those capacities and even the loss of the potential for those capacities. The other is to claim that even if the areas of the brain that are the physical basis of an individuals higher psychological capacities are destroyed, that individual remains genetically or otherwise constituted to be directed toward the possession (though not the develop- ment) of those capacities as long as he or she remains alive. I think the former of these two claims is more plausible, in part because it provides a basis for the pos- sibility of wronging the dead. Moral claims can not only survive an individuals loss of capacities the possession of which was once necessary for the individual to be able to exert those claims, but can even survive the death of the person who is the source of the claims. This content downloaded from 128.205.114.91 on Mon, 22 Aug 2016 20:32:58 UTC All use subject to http://about.jstor.org/terms 88 CHALLENGES TO HUMAN EQUALITY possession of a rational nature is sufficient to bring an individual within the scope of liberal egalitarian principles.10 There remains the familiar question about the potential for rationality as a basis for this moral status: namely, why should an immature human beings internal directedness toward the development of a rational nature affect how we ought to treat that individual now? There is, of course, a good answer to that question in cases in which how we treat the individual now will affect her for better or worse later, when she actually has a rational nature. But there are certain types of act the effects of which are limited entirely to the present, including - crucially - acts of killing. Why should the morality of an act of killing be governed by the kind of respect that is appropriate for a nature that the individual killed does not have now but may have later, though only if it is not killed? Why should an act of killing not be governed instead by due consideration for the nature of the individual at the time of action (or of the death, if it occurs later)? I believe, as I argued in The Ethics of Killing, that there are no good answers to these questions. I will not rehearse those arguments here but will instead raise what I think is a more difficult question. What reason is there to suppose that all human beings are in fact internally directed or programmed toward the development of a rational nature? There are some human beings - those who are congenitally and radically cognitively impaired (henceforth the radically impaired) - who in at least one obvious sense lack the potential for the development of a rational nature. While most immature human beings (embryos, fetuses, newborn infants) will, given a favorable environment, develop a capacity for rationality, those immature human beings that are radically cognitively impaired cannot develop this category, even with the most extensive forms of assistance that we are currently able to provide. For Kumars suggested strategy to succeed, there must be a clear and morally significant sense in which the present nature of the radically impaired is internally directed toward the development or realization of a capacity for rationality, or rational self-governance. Perhaps the most plausible claim for the defender of this strategy to make is that the inherent tendency toward rationality is present in the human genome, which the radically impaired share with the rest of 10 Perhaps there are exceptions in rare cases, such as extreme instances of psy- chopathy, in which a human being has a developed capacity for instrumental rationality but utterly lacks certain other capacities necessary for moral agency. I will not explore this possibility here. This content downloaded from 128.205.114.91 on Mon, 22 Aug 2016 20:32:58 UTC All use subject to http://about.jstor.org/terms JEFF MCMAHAN 89 us. Their essential nature is thus inherent in their genes, but its development or expression is impeded because the action of the genes that direct the proper growth of the brain is somehow blocked. It may be that their action is countermanded by some other malfunctioning genes, or that something that is required for their activation is missing, or that some of them are defective in some way. If the genes for the proper growth of the brain are present but something prevents their activation or blocks their action, there is a clear sense in which the potential for a rational nature is present. But it is less clear how long that potential persists. For the potential consists in the ability of the genes to direct the growth of a normal human brain, which is the physical basis of the capacity for rationality. But if the action of the genes is impaired and the brain grows abnormally, it appears that the potential for the growth of a normally functioning brain has been lost. For the genes cannot direct the growth of the brain once it already exists. If, even at this point, those genes could direct the reconstruction or augmentation of the defective brain in an identity-preserving way, then the potential, or inner directedness, toward a rational nature would remain; but to the best of my knowledge there is no reason to believe that the relevant genes have that capacity. If that is right, then radically impaired human beings whose condition results from the blocked functioning of normal genes lose their internal directedness toward the possession of a rational nature very early in life, when the development of their brains passes a certain point. What if the defective growth of the brain results not from the blocked action of normal genes but from defects in the genes themselves? Is it nonetheless the nature of these radically impaired human beings to be rationally self-governing? It seems as if these individuals were never internally directed toward the development of the capacity for rationality but were always directed toward the development of the cognitive capacities that they in fact have. Consider an instance in which defective human genes direct a human brain to grow in such a way that, when fully developed, its cognitive powers are no higher than those of some lower animal. Certainly in functional terms, and perhaps in structural terms as well, these genes more closely resemble the corresponding genes of a lower animal than they do their normally functioning human counterparts. Indeed, because these defective human genes function to produce a brain with powers of cognition similar to those of a lower animal, they are less similar in functional terms to their properly functioning human This content downloaded from 128.205.114.91 on Mon, 22 Aug 2016 20:32:58 UTC All use subject to http://about.jstor.org/terms 90 CHALLENGES TO HUMAN EQUALITY counterparts than are the corresponding genes in a higher animal, which function to produce a brain with cognitive capacities closer to those of a normal human brain. On what basis, then, can it be claimed that it is the inherent nature of the individual whose genes these are, but not the nature of a higher animal, to be internally directed toward the realization of a capacity for rationality? We have thus far considered that radical impairment could result either from the suppression of the action of certain genes that carry the code for the development of the human brain, or from defects in the genes themselves. But there is another possibility. Some of the relevant genes could be entirely absent. Whether such cases occur or have occurred naturally is a question on which I have no information. But even if they do not occur spontaneously in nature, they could presumably be created by manipulating a pair of human gametes prior to fertilization in a way that would ensure the deletion of certain genes necessary for directing the normal growth of the brain. The resulting radically impaired individual would certainly be a human being by any reasonable criterion of species membership, whether that criterion referred to genes, genealogy, capacity for interbreeding, or whatever. There would then be a human being without any genetic basis for the development of a rational nature. It would therefore be hard to make sense of the idea that this human being would be internally directed toward the full realization of its inherent nature as a rational being. Suppose there were a human fetus in this condition - that is, one lacking some of the genes necessary for the development of a brain with the capacity for rational thought. There is one sense in which this individual might have the potential for a rational nature. Suppose there were a therapy that could supply the missing gene or genes and that if it were administered to the fetus, that fetus would grow to produce a person with normal cognitive capacities rather than being radically impaired. And suppose further that the transformation would be identity-preserving, in that the person would be the same individual that the radically impaired individual would have been. The therapy, in other words, would determine whether one and the same individual would have normal …